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The skinless work group: facing the uncertainty of resting on a void

International Journal of Applied Psychoanalytic StudiesInt. J. Appl. Psychoanal. Studies (2015)Published online in Wiley Online Library(wileyonlinelibrary.com) DOI: 10.1002/aps.1430 The Skinless Work Group: Facingthe Uncertainty of "Restingon a Void" MATÍAS SANFUENTES This paper examines the conflicts and resistances that contemporary organizationsface in the effort of generating new and challenging work opportunities. Assumingthe metaphoric and real character of the ‘body of the organization', differentdilemmas that work groups tackle in the generation of collaborative and productivespaces are described. Based on a socioanalytic consultancy carried out with agroup of Reichian body psychotherapists, the study illustrates the complexities todelineate a common strategy and to overcome the threatening porosity and incon-sistencies of the ‘institutional skin'. The lack of a body support is particularlyparadoxical for a group of psychotherapists that base their therapeutic method onbody techniques, and which crystallizes as an institution the place of rejectionand exclusion that Reich and the concern for the body have historically occupied.
Copyright 2015 John Wiley & Sons, Ltd.
Key words: body, skin, organizational boundaries, Reich INTRODUCTION: THE BODY OF ORGANIZATION Organization theory has been greatly influenced by the use of the biologicalmetaphor of the body. The notion of "organization" is actually derived from thatof "organ", which represents a particular section of the body adapted to performcertain functions. Thus, organizations can be defined as "organized bodies" thatare split into parts that operate in a structured and connected way, with anidentifiable boundary and with a common goal. This way of understandingorganizations is also guided by the "machine" metaphor, that implies that organi-zations can only operate correctly when their parts are connected in particularways. This concept emphasizes the urge to structure, delineate, and define underthe notion of rationality, which are the pillars of Cartesian Modernism. In this Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
context, emotions, differences, and contradictions are segregated and obscuredby the predominance of an organizational functionalist perspective (Dale &Burrel, 2000).
Since Freud (1921) onwards, psychoanalysis has provided alternative views regarding the understanding of the functioning of groups and organizations. Thisperspective has explored and delved into aspects that not only explain thestructures and functions of groups and organizations, but also the emotional and ir-rational side of them. This implies viewing these collectives as living organisms com-posed not only by anatomical structures but by "bodily fluids" as well (Carter, 1983).
Such bodily fluids metaphorically represent the complexity (Stacey, 1995) that isdifficult to integrate into more rational paradigms to understand organizational life.
In a similar vein, socio-analysis (Bain, 1999), as a discipline developed at theconfluence of psychoanalysis, social systems thinking, group relations, and organiza-tional behavior, has also contributed to offer a wider and deeper picture of organiza-tional life.1 This attempt to understand the complexity of organizations is achievedby employing models that integrate bodily, mental, and social phenomena.
This paper examines the metaphor of the "body of the organization" (Morgan- Jones, 2010), in both the symbolic and material connections that can beestablished between the body as a "psychic envelope" (Anzieu, 1990; Houzel,1990) and the organizational life. From the contributions of several psychoanalyticauthors (Anzieu, 1999; Bion, 1961; Kaës, 1993), this text explores the relevance ofthis metaphor as a symbolic function that enables group members to containpsychic objects, to delineate working spaces, and to protect them in consistentand flexible containers. Failures in the capacity of performing these functions aredescribed through a case study, which explores the negative effects on members'capacity to face uncertain contexts and to explore organizational challenges.
The paper discusses in what manner the difficulty to deal with the task risks andconflicts are actualized by the dramatic failures to contain and think about themcollectively. Moreover, it illustrates the application of socio-analytic consultancymethods to work with organizations that are experiencing turbulent and conflic-tive periods, because of their incapacity to take action.
GROUP AND ORGANIZATIONAL BOUNDARIES Psychoanalysis has significantly contributed to clarifying and conceptualizingdynamics that regulate the fragile balance of the individual's mental andemotional experience. The entity in charge of keeping an adequate and stablebalance is the Ego. Freud (1923, p. 26) defines the Ego as "a bodily ego; it is notmerely a surface entity, but is itself the projection of a surface". This definitionstresses the process of displacement by which the Ego is constituted in relationto the bodily and sensory structure that provides the basic materiality to the humanexperience. In this way, the body sets some limits to the Ego in its permanentstruggle to find consistent supports to provide a certain degree of stability andcontinuity to the individual's existence. Nevertheless, such anatomic borders are Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
The skinless work group: Facing the uncertainty of "resting on a void" permanently overwhelmed as a result of the precariousness of the body as a reliablereferent for the Ego, which is formed through a reflected image of the intersubjec-tive relation with the Other.
Freud's conceptualization of sexual instincts is strongly anchored in the body.
The source of the instincts represents the somatic moment from which theexcitation arises enabling mental life to unfold. Each partial instinct has itsown erotogenic zone that determines the specific properties and conditions ofthe instinctual aim (Freud, 1905, 1915). This model has insufficient resultswhen the analysis attempts to adequately explain the links between group andbody, since other elements must be considered. Nitsun (1996, p. 46) claims thatthe group as a concept is both "paradoxical" and "elusive". Groups not onlydiffer according to their basic characteristics (size, form, purposes, duration, etc.),but also, for some authors, the very existence of the group as an entity isquestioned. One of the principal reasons for this elusiveness resides in the fact thatthe group lacks a physical body that operates as a boundary for the mental andemotional life of the collective. The group's limits are in a permanent state of fluxas a result of the multiplicity of interactions taking place in the here and now.
From this perspective, there is no other material evidence of the group as a unitapart from being a collection of individuals gathered at the same place and time.
Although such individuals can experience the impact of the group-as-a-whole –as something that acts beyond the single contribution of each member – this issomething that inevitably operates in their minds.
In a similar vein, Kaës (1976) claims that unlike the individual psychic apparatus, which has a constant and continuous biological basis, the "grouppsychic apparatus"2 has a mobile and discontinuous relation with their materialsubstratum. The group psychic apparatus only has a phantasied body, and one ofits main functions is to provide a bodily prosthesis, which emerges from the cre-ative interaction between members. Kaës (1976) states that in order to "achievea body", group members need to deny their singular bodies to incorporate an imag-inary bodily unit. This creates a tense dialectic between the individual and collec-tive poles, which increases unconscious pressures placed on group members takingup different group roles. Some of the pressures follow a tendency towards mentaland emotional homogeneity with respect to the group's psychic apparatus, butothers reinforce the individual differentiations of processes, meanings and roles.
According to Bion (1961), the illusory belief in the existence of the group implies a massive regression to primitive forms of mental functioning of apsychotic quality, in which members lose their "individual distinctiveness".
The prototypes of these regressive group experiences are the basic assumptions.
These phenomena are group mentalities that manifest powerful emotionaldrives. They do not need training, experience, or mental development, but onthe contrary they are instantaneous, inevitable, and instinctive. They areexpressive of the fact that the individual's contribution to the group life isunavoidable. Bion claims that these group mentalities arise from a proto-mentalsystem that is described as a matrix in which physical and mental phenomena Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
are undifferentiated. Thereby, from this matrix basic-assumption emotionsspring to strengthen, permeate, and sometimes dominate the group's mental life.
He maintains that within the proto-mental system the prototype of every basicassumption is present, "each of which exists as a function of the individual'smembership of the group" (Bion, 1961, p. 101). Consequently, proto-mentalphenomena have to be understood in the group and never with sole referenceto the individual.
Torres (2010, pp. 56–57) claims that, like the Freudian concept of the id, Bion's concept of proto-mental is a "topographical metaphor" that representsphenomena that operate in the interface between body and mind. Moreover,both concepts characterize "soma-psychic undifferentiated processes" from whichaffective and mental experiences originate, thus becoming overt behavior andmental awareness. Finally, the two concepts represent the "bio-psychic" basesof human motivation. Nevertheless, Torres considers that, unlike Freud, theidea of the proto-mental system is built upon a social foundation, which isessential in Bion's theory to understand the manifestation of any mental pro-cess. For Bion (1961, p. 133) the individual's gregarious tendencies are alwaysin play, and consequently they are part of the individual's "equipment as aherd animal".
Bion (1961) conceptualizes the action of the basic assumptions in connection to what he describes as the work group mentality. Accordingto him, the group always meets to "do" something in a cooperative way.
He conceptualizes this cooperation as structured, voluntary, geared to aparticular task, and whose methods are rational. However, the functioningof the work group can be obstructed and diverted by the basic assumptions.
The predominance of the work group over basic assumptions depends on theexistence within the group of clear boundaries and roles, adequate leader-ship, and achievable tasks.
Bion's (1961) model provides a view that integrates bodily, mental, and social processes for the understanding of many aspects of the human experi-ence. Following that tradition, Morgan-Jones (2010) connects the notion ofproto-mentality with other socio-analytic contributions to analyze the socialand work place ailments. Through what he calls a socio-somatic level ofanalysis, he describes the socio-dynamics of different kinds of emotionalcontainment within the context of several working organizations. Heexplores the way in which a group's containment responds to traumaticexperiences of emotional overload, and how that is expressed by thebreaching of the boundaries of the group's body. This implies focusing on "what happens across the boundary of the group that can be thought of asa skin" (p. 82).
The notions of boundary and/or skin3 represent a function that mediates the exchange between the individual and the group, and accordingly the sub-jective and intersubjective experience of these contacts. In this process, mem-bers need to keep the balance between their internal and external boundaries.
Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
The skinless work group: Facing the uncertainty of "resting on a void" According to Slater (1966) the maintenance of such boundaries is extremely"energy-consuming and tension-inducing". Consequently, he considers thatboundaries are defined by this tension, and that all tension results from theindividual's attempts to preserve the connection between different domainsof experience. When the preservation of boundaries is threatened, the indi-vidual feels a "sense of envelopment". In these cases he or she becomes awareof the blurring of boundaries that keeps him or her separate from the group,by experiencing a sudden contact with unknown feelings and impulses. Insuch moments, the individual feels "swept away by forces that seem to comeboth from within and from without" (p. 179).
Turquet (1975) also employs the notion of skin to describe the mental life of large groups. From his perspective, as well as the baby in its first phases ofdevelopment, the individual in the group must also achieve a skin that limitsand defines him or her as a group member. This boundary is attained in theinterplay between his or her inner internal features and those of the group.
The establishment of both an external ("the-skin-of-my-neighbor") and inter-nal skin allows the individual to get involved in the group life, thus obtaining asense of continuity and the capacity to process his or her experiences.
The concept of skin also has a significant place in Anzieu's (1985) theoreti- cal developments. He calls this frontier structure "psychic envelope", or, morebroadly, "Skin Ego". According to Houzel (1990), a psychic envelope not onlycontains the elements of the psyche, but also tries to establish continuity thatallows the individuals to define spaces and achieve communications betweenthem. Houzel describes the concept of psychic envelope by comparing it witha field of force, like the one formed around a magnet that organizes anysurrounding iron filings according to precise forms following lines of strength.
From this perspective the psychic envelope may be considered an "attractor"(Houzel, 1990, p. 44); a form whereby the acting force is molded, accentuatingits unifying and protective functions of psychic interchange.
The psychic envelope carries out five central functions. First, it contains and promotes the connection between internal objects, thus preventing its dispersalin a limitless space. Secondly, it protects the mind against an excess of stimulationfrom the external world. Thirdly, it demarcates a boundary between the internaland the external world. Fourthly, it connects the external face of the psychicenvelope with its internal face. Fifthly, it differentiates the psychic envelope inits contacts with the external reality (Houzel, 1990).
Anzieu (1999) applies his concept of skin-ego to describe the group reality.
In this sense, for him the group is "an individual body with an esprit de corps … [which is] enveloped by a group ego" (p. 319). He describes this envelopeas a common place in which group phantasies and feelings are pooled and sharedby the different individuals. These phantasies are circulated among them andpoint out spaces of interdependence between individuals and variables of thegroup's functioning. The disparity between each individual's unconsciousphantasies may generate group disunity; however the convergence of them Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
may produce a common ideology that may be either defensive or constructive.
These phantasied elaborations might have a brief or stable presence in themental life of the group (Anzieu, 1975/1984).
Anzieu (1999) situates the main conflicts of group life at two levels. Firstly, they arise from the clash of antagonistic tendencies displayed by the individualand the group. At this level, the struggle is chiefly narcissistic: "the group tearsaway individual psychic skins and sews them on to a narcissistic group envelope"(p. 320). Secondly, the conflict is replicated in the relationships between groupand society. Thus, each collective sphere attempts to place the other at theservice of itself, from which a tense dynamic emerges. As a reaction, the groupintrojects an envelope of norms and regulations that allow its self-regulation.
He calls this formation "muscular group envelope". Anzieu considers thatbetween these narcissistic and muscular envelopes the group develops a psychicgroup skin, which operates as "an extension to the group of the individualego-skin and constituted by a double support of individual ego-skins and thesocial ‘body'" (1999, p. 321).
Representing a group of Reichian body psychotherapists, Pedro4 contacted me tohelp them solve a profound crisis that the group was going through. Five yearsago, they had formed a small professional association of Reichian psychothera-pists that sought to develop diverse training projects in psychotherapy and alsoin the consulting field. However, over the years, the small organization has beenlosing focus of its primary task5 becoming virtually paralyzed. In fact, the mem-bers only officially met four times a year to receive supervision for their clinicalwork from internationally renowned experts that they flew in from abroad.
Therefore, the group found itself facing a difficult dilemma, and as a conse-quence, needed to urgently resolve the viability of the project and its continuityas an organization.
The group consisted of seven members (five women and two men), all Reichian-oriented body psychotherapists whose ages ranged between 37 and45 years old. Initially the organization consisted of 12 members; however, five ofthem had left the group, some under quite traumatic and disturbing circumstances.
They had followed the same career path for more than 10 years, which had beenclearly marked by a training process in body psychotherapy with distinguishedmembers from a European Reich-oriented training school. This meant that formore than four years all of the members had placed a lot of effort into financingthe periodical arrival of important representatives from this school to Chile, whichenabled them to complete their training.
The consultation process was developed throughout eight group sessions, averaging three hours each, during a period of five months. In these sessions, Iemployed organizational role analysis (ORA) methods, whose theoretical and Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
The skinless work group: Facing the uncertainty of "resting on a void" technical principles are derived from psychoanalysis and systems theory (Newton,Long, & Sievers, 2006). ORA is a particular kind of individual and group consul-tancy that seeks to analyze, understand, and clarify the person's role in the contextof the system to which he or she belongs. Through a collaborative associative workbetween consultant and client(s), the role, conceived as "a mental regulatingprinciple", is explored in depth with the purpose of improving both the clientand the system's performance. The role is a psychic construct that mediates thelink between the person and the system in which he or she takes up the role.
ORA supports the client to find and make a role that adequately responds to theperson and the organization's needs (Reed & Bazalgette, 2006). Taking a role isalways a dynamic process that requires being aware of a multiplicity of factorswhich may hamper the person's capacity of managing adequately the system'sprimary task. The focus of this psychoanalytically oriented consultancy is thecomplex interplay between the individual's personal psychodynamics and theorganization's psychosocial dynamics (Sievers & Beumer, 2006). In this particularconsultancy, we carried out several sessions of role analysis, in many of which weexamined the role drawing of each member within the context of the group(Nossal, 2010). The process of associative group exchange permitted them todelve into some of the psychodynamics that explained the difficult emotionalreality of the work group, both at an interactional level as well as in terms of thegroup-as-a-whole.
Floating in a Sea of Emotions and "Resting on a Void" In my first meeting with the group, what caught my attention the most washow the members unanimously referred to being primarily united by strongemotional bonds of a loving character. They described themselves as a groupof brothers, "fellow travelers" with a common training. The group was thusestablished for support in terms of the theoretical Reichian paradigm, whichessentially shaped their professional identities. They represented themselvesas a collective space of emotional containment, where their loving bondspredominated at the expense of their ability to interact with each other morecritically and divergently.
This lack of critical spirit was detrimental to the overall operation, since they found it extremely difficult to openly discuss their differences. This greatlyaffected their decision-making process and their capacity to define the fate ofthe organization. While everyone experienced a level of frustration and suffer-ing, they all showed it in different ways; the situation created a great deal ofstress for everyone. The members felt a deep sense of mistrust in the individualand collective means that they counted on to implement joint activities in theeducational, clinical, and Reich-based prevention fields. The lack of commit-ment that each member perceived in the others increased their distrust in theavailable resources, as well as the uneasiness and anger that they had towardeach other and toward the group as a whole. In this way, the group was lacking Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
a collective body that could sustain and articulate its abilities and individual mo-tivations, which caused them to fluctuate ambivalently between the protectionthat they found in the loving group space, and what some defined as "resting ona void".
This "resting on a void" was sustained by massive denial mechanisms, and it resulted in acute symptoms that demonstrated the profound inconsistency andporosity of the institutional space. For example, no one wanted to assumeresponsibility for the group; the response to the collective emails was verydeficient and at times non-existent; no one was in charge of updating theinstitute's web page; all of them had stopped paying the institute's fees. All ofthese symptoms were accompanied by deep fears relating to the possible extinc-tion of the group, or its fragmentation through the traumatic loss of moremembers, as had happened before. They also had visions of infertility, in theirinability to get results and to be able to train other Reichian body therapists.
Some of them were ashamed to not be able to respond adequately to the interestthat many people expressed in training in this field. Many of those who wereinterested kept anticipating the beginning of the psychotherapy training process,which they were never able to consolidate or implement. Finally, they felt therisk of atomizing themselves, fearing that the individual and collectiveknowledge that they possessed would be irretrievably lost and diluted in theabsence of a binding body.
These symptoms of institutional paralysis were very contradictory with respect to the abilities and achievements that each one had gained outsideof this collective space. Everyone had a private practice as a well-establishedpsychotherapist, and many of them were actively teaching and consulting inother areas of work. Some belonged to or had developed other training insti-tutions that had done very satisfactory work. But when they tried to create acommon project – in what represented for them the greatest conceptualreference for their psychotherapeutic practice – they countermanded each other,losing all ability to harness their resources and abilities to serve the institution.
All the difficulties that the group was facing might be summarized in the generalized belief that they had to deeply reformulate their goals, or they wouldinevitably disappear as a work group. This precarious institutional situation ledme to think about what Hirschhorn (1999, p. 9) calls the "primary risk". Hedefines it as "the felt risk of choosing the wrong primary task, that is, a task thatultimately cannot be managed." The group was embedded in an extremely ambig-uous state that prevented them from making any kind of decision concerningtheir future. Some of them wanted to implement the previously plannedtraining institute. Others were in the position of initiating small educativeprojects, such as open seminars and short training activities. Others wanted towork in health prevention using Reichian techniques. Finally, others were veryconfused regarding their position and role within the group. This created asignificant zone of "task ambiguity", where as Hirschhorn (1999) suggests,individual and collective vacillation and ambivalence play a key role.
Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.



The skinless work group: Facing the uncertainty of "resting on a void" The "Lost" Body and Organizational Disembodiment During the first role analysis session, we worked with the drawings of three groupmembers. One of the key dimensions that appeared in the analysis of thesedrawings was the experience of disembodiment that the members experiencedwhen they visualized themselves inserted into the organization. In every case,individual embodiment had a tendency to be diluted in the space (Figure 1),or rather, it was represented through big heads lacking a body to support them(Figures 2 and 3). In this context, the mental dimension appeared hypertrophiedat the expense of those body parts that permitted to integrate the distinctmembers (the body) and also mobilize themselves in the space (the extremities).
For the group, it was very significant and distressing to identify with the feeling ofbeing afloat in the air without a material support base, and without extremitiesthat permitted them to mobilize themselves and to undertake actions in adefinite sense.
Figure 1: Flavia's role drawing.
Figure 2: Pedro's role drawing.
Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.


This experience of disembodiment that appeared in the distinct drawings connected them with a reality that was very difficult for them to integrate into,since it showed them exactly the blind spots and the gaps of the primary focusfor a Reichian body therapist: to work with the patient in the integration ofthe stiffened segments of their corporality.6 To identify with the image of the"lost body" was a threatening experience that demonstrated the intenseanxieties of disembodiment that they experienced with their clinical work,which was expressed as much at the individual level as it was at the group level.
In fact, the members constantly made reference to the difficulties that they hadtackling the Reichian methods of practice individually, and that therefore, tobe able to adequately implement projects in this field required the collaborationof the group as a whole. Nevertheless, all of their attempts to create such a frame-work for collective action had failed irreparably.
Bleger (1970/2002) claims that all organizations tend to defensively reproduce a structure similar to the problem that they have to face, and for which they havebeen designed, which can create high levels of dysfunction in completing the task.
In this context, the group unknowingly generated a social defense system(Menzies, 1960/1989) to protect itself from the complexities that the completionof their shared primary task demanded. The "lost body" was an "emergent"7(Pichon-Rivière, 1970/2003) that demonstrated the precariousness of the group'soperation. Therefore, it was at the level of the collective body in which theanxieties of disembodiment appeared in their most intense form, thus exacerbatingthe action of fragmentation dynamics that overruled the individual and collectivegroup resources.
As shown in Fernanda's drawing (Figure 3), her organization-in-the-mind (Hutton, Bazalgette, & Reed, 1997) is represented by a circle marked by aprecarious boundary that separated the interior from the exterior. Six heads thatillustrated her group mates were in the interior expressing the emotional states Figure 3: Fernanda's role drawing.
Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.


The skinless work group: Facing the uncertainty of "resting on a void" that each one had assumed over time. The drawing created a great deal ofanxiety and a great sense of emptiness for the group members, who perceivedthemselves as "stunned", unable to move or interact with each other. The onlymovement possible was flight, which was represented as much by the membersthat had previously left the institution – who in the drawing appeared leavingin an airplane – as by the dubious position of Fernanda, who was torn betweenstaying or leaving the group. Working through her hesitant position with respectto the group was very important in the consultancy last phases. The figures thatwere outside the group were depicted with complete bodies, but those whostayed within the group were disembodied.
Paradoxically, at the center of the drawing was a treasure of gold coins covered in dirt that represented the immense value that the group granted tothe Reichian theory and practice. The treasure in the drawing stood out becauseits color was very alluring, but at the same time it was extremely ironic and con-tradictory, since it showed the inability of the group to divulge the knowledgethat they highly valued. The anxiety, blame, and sadness that they exhibitedin the face of the difficulties they experienced in disclosing such ideas were verysignificant.
"Antuco": The Risks of Being in Limbo The next session was marked by the associations that emerged from the analysis ofMiguel's drawing (Figure 4). According to its author, the drawing represented allthe group members on an "excursion" in the midst of nature, trying to convey apleasant and cheerful environment. According to Miguel, the rivers representedtwo important moments of crisis that the group had experienced in the past: first, Figure 4: Miguel's role drawing.
Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
the severing of ties with the members of the European Reichian School that hadbeen in charge of their training as body psychotherapists; and secondly the painfuland tragic loss of two highly valued group members. The larger size and volume ofthe second river was directly associated with the powerful emotional repercussionsthat the second crisis entailed for the group. The drawing demonstrated a temporaland spatial confusion, since the members were descending, but toward events thathad already occurred in the past. This reinforced the feeling of timelessness, ambiv-alence, and a lack of clarity in the direction that the group was going at the time.
While Miguel did not accept these hypotheses altogether, it was relevant to note the associations that the analysis of the drawings awakened in the rest ofthe group. Furthermore, some members reaffirmed the uncomfortable sensationof perceiving the group in a state of constant back and forth, and therefore ofgreat paralysis and ambivalence. The drawing also created a sense of instabilityand threat. This feeling of uncomfortableness was exacerbated by the remaininggroup members' contributions, who expressed their discomfort and anger atbeing a part of a group that identified with a path of pain and suffering. In thereflexive group process, Pedro associated the drawing with the tragedy ofAntuco, as confirmation of the state of fear and confusion in which the groupfound itself. Antuco is a volcano located in southern Chile in a mountainousvicinity at 1500 m above sea level; where in May 2005 44 recruits died tragically,many of them teenagers that had been in the army for less than three months. Inwhat was a routine training mission, the major in charge of the regiment ordered474 recruits to march 28 km in extreme climate conditions and without theequipment and clothing necessary for such a setting. A snow storm batteredand completely disoriented the group, causing 44 of them to die from hypothermiabefore they could reach their destination.
The members' associations regarding the tragedy and the painful implications of feeling lost and paralyzed as a group heightened the level of anxiety consider-ably during the session. The group's identification with the recruits totally lostand without sufficient equipment and preparation to face the storm, connectedthem to a deep sense of precariousness and lack of containment. Pedro, who inthe drawing appeared ahead of the group in a clear position of leadership, angrilyexpressed his reticence to participate, let alone to lead, a project that producedthis kind of negative emotions. Pedro was seen by the group as the naturalleader. Nevertheless, the other members' passivity and strong dependence onhim had worn him down and limited his will to lead an erratic and confusedgroup. While he had never formally held a leadership role within the group,his personal abilities and his commitment to the project had lead him to assumea more active role, which he had no interest in continuing. The clarity of thisstatement had a powerful impact upon the rest of the members, since it set aclear boundary that left behind a very unfruitful and wearying type of leadershipwithin the group.
The connection of the group's emotional state with the fallen recruits of Antuco in the freezing cold brought to the surface, in a displaced way, the strong Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
The skinless work group: Facing the uncertainty of "resting on a void" emotional impact that the loss of important members – who had suffered the risksand emotional costs of assuming leadership positions – had on the group. Forexample, Francisco, one of the most mourned group casualties, had left angrilyafter having tried to actively "conduct" the group toward the implementation ofthe training Reichian Institute. The hostility of his departure deepened the groupcrisis, emphasizing fears of fragmentation and instability, so that the emergentAntuco materialized crudely during the session. Tacitly, the group seemed towonder about the source of the feeling of collective instability that they wereexperiencing. Individually, each one was a highly competent professional thatnevertheless felt reduced to the status of a novice when they tried to set out ona common path. Inevitably, these questions led them to the figure of WilhelmReich and his intense and prolific life, full of significant accomplishments but alsoplagued by tragic conflicts and failures. Their identification with the marginalityand stigmatization of Reich's ideas and methods was a heavy burden from whichthey found it difficult to liberate themselves.
The Reichian Bastard One of the elements of analysis that emerged during the consulting process, andthat could explain in part the difficulties of the group, was determined by a seriesof dynamics that resulted from the relationship that the members had with theReichian theories. This group seemed to embody contradictory elements linkedto the significance that its members – and what they perceived in their environ-ment – attributed to the Reichian paradigm. On the one hand, for the group thisknowledge represented a very sophisticated conceptual and technical treasure thatthey hoped to be able to communicate and pass on to others. On the other hand,they also felt very ambivalent about being able to articulate and teach these ideasthat they felt were "too great", due to their revolutionary and counter-culturalcharacter, as well as because of the almost-religious qualities that they attributedto the Reichian model. Moreover, their identification with this paradigm madethem feel embarrassed with respect to the outside world. The members felt unqual-ified and socially isolated because they were bearers of the Reichian lineage.
This embarrassment was transmitted in all of its intensity through the emergent of the "Reichian bastard", which the members utilized throughoutthe sessions to refer to themselves, and which revealed them as representativesof a tradition that was embarrassing, discriminated against, and penalized. Thisemergent inevitably connected them with the vulnerability and stigma of thebastard experience of lacking the social acknowledgment that a paternal lineageprovides. They felt hopelessly part of a tradition that connected them to thetragic life of Wilhelm Reich, the genius that heralded the pursuit of pleasureand the orgasmic experience, but who died a prisoner, with his ideas and bookscensored and burned, and surrounded by persecutors, both real and imagined(Sharaf, 1983/1994). Linked to the tragic fate of identification with this Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
paradigm, Pedro remembered that when they completed their training inpsychotherapy, the Director of the Reichian Institute said to them: "Welcometo the club of fools". The weight of this irony in light of the group's problemsbecame a cruel prophesy from which they desperately wanted to break free.
The group's identification with this phantasy of discrimination and madness did not only respond to elements that stem from the action of the members'individual and interactional dynamics, but also to how they embodied a powerfulsymbolic negative stigma linked with Reich's life and work. In this way, the groupwas trans-subjectively (Kaës, 1993) identified with this heavy collective burden.
This kind of identification implies an unconscious alliance between the groupand the conflictive link with Reich's legacy. This is an alliance that entails ashared psychic reality between individual members and the collectives that theybelong to. This intersubjective psychic formation determines the quality of linksbetween members, thus reinforcing in them certain functions and processes thatbecome decisive for their mental life. Accordingly, this unconscious alliance hada particular structure, economy, and dynamic that heavily contributes to thestagnation of the group's collective functioning.
This also makes reference to what Anzieu (1999, p. 321), following Lacan, calls "symbolic group skin". This aspect of the group skin provides "signs of belonging tothe group", such as uniforms, rituals, and professions of faith. Moreover, it mediatesthe conflictive relationship between group and society.8 In the analyzed case, thegroup was symbolically identified with very ambivalent and contradictory aspectsconnected with Reich's life and theories. On the one hand, members hadintrojected very punitive and devalued aspects related to the critical and hostilesocial appreciation of Reich's theoretical and technical contributions. But onthe other hand, they had idealized his ideas and methods as a matter of faith,feeling themselves incapable of using them in plenitude. These contradictionsare at the core of Reich's life, which was mainly characterized by high achieve-ments, but also by very painful falls.
Trapped in Mutual Distrust Toward the end of the fifth session, in which we were concluding the analysisof the seven role drawings, a deep climate of mistrust began to intensifyamong the different members. In spite of the fact that the completed analysisup until this moment had allowed them to work through their difficulties, acollective dynamic of tension and resistance to change could still be sensed.
My counter-transference to the group dynamic was very negative, which ledme to convey the interpretation of feeling them "dragging a dead man", aheavy burden of mistrust that prevented them from moving forward or makingdecisions.
During the next session, we analyzed the particular way in which each of them envisioned himself contributing to the collective institute project. In thissession, I observed a high level of understanding between them regarding the Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
The skinless work group: Facing the uncertainty of "resting on a void" desire to strengthen the existing collective structure, through which they coulddevelop activities in the field of psychotherapy training, and also in the develop-ment of new projects in the area of early childhood prevention. Moreover, every-one was willing to contribute with a weekly time frame for meeting, developing,and consolidating those challenges that they were planning for.
This constructive dynamic was abruptly cut short by Fernanda, who announced her intention of leaving the group due to strong differences thatshe had had three years before with two other members of the group (Flaviaand Teresa), on a project in which the three had worked conjointly. None ofthe four remaining members knew about this old conflict. Fernanda said thatit would be very difficult for her to work with them again. The emotional impactof this declaration was very great for the group since everything they had builtseemed to shatter into a million pieces. During several months the group hadworked hard toward developing a common project, however this revelationshowed how extremely fragile their support base was. The conflict that existedamong the members gave shape and substance to my negative counter-transference from the previous session. A deep sense of unease overwhelmedthe entire group. The end of the session required us to resume our analysis ofthe situation in the next session.
During the next meeting, the group explored in more detail the strong emo- tional repercussions that had caused the conflict experienced by Fernanda andher two colleagues years ago. The opening up of this conflict allowed Fernandato face her hesitant position concerning the group's primary task and future, whichwas initially described in the analysis of her drawing (Figure 3). At this point, shetackled the group's difficulties to cope with their disagreements and disputes, aswell as her tendency to remain in a secondary position, mainly in charge of thegroup's operative duties. The session was extremely intense in emotional terms,throughout which several women cried, expressing their sorrow over the possiblebreakup of the group. At one point, Pedro revealed his exhaustion with the groupdynamic, which he described as "feminine", claiming that he greatly missed thegroup's ability to more proactively face the challenges that lay ahead, rather thanto remain trapped in the circularity of emotions. This stirred the rest of the mem-bers considerably, who appeared surprised and challenged by Pedro's words. Whenwe only had a few minutes left before the end of the session, I proposed to themthat they should meet without me for the following sessions, and then resume workwith me a month and a half later. The group agreed.
When we reconvened after the agreed time period, the collective dynamic seemed very different. Cecilia told me upon greeting me: "your interventionworked". The group had met independently three times, and they managed to find a common ground in the interests that everyone had. In that period, theycreated a framework for the coming months, distributing tasks and also dedicat-ing their time and energy to future challenges. They decided to begin developingprojects more closely related to the training of psychotherapists and to resume thework that they had proposed in the field of early childhood prevention. They Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
recounted feeling greater consistency in the group's resources, and also notfearing a potential failure in the new challenges that they were proposing. Theyalso felt that they had broken free from the heavy burden that the members of theEuropean Reichian School in charge of their training had passed on to themyears ago. For many years, they had felt pressured to replicate in Chile the sametraining that they had had. Now they felt that they could inhabit a collectivebody that was more real, where they could better coexist with their own ideas,dreams, and challenges.
This paper describes some of the complexities that groups face in the effort ofharnessing their resources to accomplish the primary task and to set commongoals. The notions of "body of the organization" and "psychic envelope" areemployed to illustrate and understand the value of exploring in depth theunconscious trends that determine the roles and interpersonal boundarieswithin the system. The case presented shows in detail the multiplicity oflevels (individual, intersubjective, group-as-a-whole and transubjective) thatis involved in the challenge of developing and preserving a healthy operationof these boundaries. From this perspective, the inconsistency and porosity ofthe psychic group skin, as well as the anxieties of fragmentation and organi-zational disembodiment that members experienced, were powerful symptomsof the lack of emotional containment that the institutional body provided.
These unconscious collective dynamics were worked through combining anindividual and group analysis. This psychoanalytic work set the basis for amuch safer, containing, and protective psychic group skin, which enabledgroup members to face more realistically their interpersonal problems, as wellas the heavy burden of a historical organizational legacy that impaired itsfunctioning. This analysis is consistent with Anzieu's (1999) approach, whoclaims that the main conflicts of group mental life reside both in the antag-onistic tendencies between the individual and the group, and in the tensionsbetween group and society. In this context, members' interpersonal conflictswere exacerbated due to the conflictive implications of working under thelegacy of Reich's shadow.
The psychodynamic role consultancy methods that guided the whole process of analysis were powerful tools to examine how members were taking up theirroles concerning the group's difficulties. These methods allowed delving intothe unconscious dynamics that sustained the conflicts of each individual withrespect to the group tasks. This analysis was greatly strengthened by the in-depthexamination of individual role drawings, which opened new perspectives to col-lectively explore and understand the main causes of obstacles to the group. Aspart of this exploration, Fernanda was able to face her ambivalent position re-garding the group; Pedro openly stated his reluctance to lead the organization,and several female members changed their passive roles in the system. The Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
The skinless work group: Facing the uncertainty of "resting on a void" progress of this analysis lay in the generation of working hypotheses (Reed &Bazalgette, 2006) which were developed by the joint collaboration betweenthe group and the consultant. Such hypotheses contributed to find new waysto examine the unconscious meanings and the emotional experience that oper-ated "below the surface" of the organization (Huffington, Armstrong, Halton,Hoyle, & Pooley, 2004).
This paper stresses the relevance of applying the concepts and heuristic methods of psychoanalysis to study the unconscious mental dynamics ofgroups and organizations. Psychoanalysis provides very powerful interpretativemeans to examine, understand, and transform what is concealed under themain symptoms individuals experience as a result of working together. Theemployment of this psychodynamic approach entails looking at transferentialphenomena and defensive mechanisms that offer essential information aboutthe irrational aspects that remain covered by the apparent order and structureof organizational behavior. Moreover, through the detailed descriptionprovided by the case study, this report reveals the benefits of developing a "reflective practice" (Hinshelwood, 1996) within groups and organizations.
This means to engage members' active participation in creation of dialogueand exchange spaces that enable them to disentangle their collective resistanceto think and change.
This research is supported by COES Centre for Social Conflict and CohesionStudies (CONICYT/FONDAP/15130009).
1 Socio-analysis as theory and method of intervention and research is built on the seminal work done by Bion (1961) with groups and expanded by theTavistock tradition (Trist & Murray, 1990) from the 1940s until the present.
Socio-analysis focuses on the study of institutions and social systems thusincluding the emotional, social, cultural, and political side of them. Thisperspective regards that individuals' roles are socially induced by the organi-zational system and by the psychic and emotional reverberations that thewider environment has upon this system.
2 Kaës (1999, p. 74) defines the "group psychic apparatus" as a mental structure ir- reducible to the individual psychic apparatus. It is a linking and transformativesystem of mental elements, that operates as a result of members' contributions.
3 Esther Bick (1968) introduced the concept of "skin" in psychoanalytic literature as a result of her prolific work on infant observation. She describesthe "skin of the baby" as a primitive boundary that has to be established inorder to facilitate the "binding together of parts of the personality not as yet dif-ferentiated from parts of the body" (p. 484). She stresses that at the beginning, Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.
these parts of the personality need to be "held together" in a passive way – withthe skin working as a limit – because in its primal form they do not have theforce to perform such a task by themselves. In this process, the baby is requiredto introject an external object that is able to carry out this function. Only byincorporating these containing functions into the self, the notion of internalspace that holds things can emerge. Likewise, this introjection allows settingin motion the operation of primitive splitting and idealization of self and ob-ject. From the point of view of the author, this introjected containing objectis "experienced concretely as a skin" (Bick, 1968, p. 484).
4 All the first names employed in this manuscript were invented to protect the identity of group members.
5 The primary task is fundamental heuristic concept in the Tavistock tradition that defines the main purpose of the organization, which is constituted frommembers' constant struggle with the need of survival as a collective. Thistask is directly related to the organization's capacity to be permanentlyadapting to internal and external changes (Rice, 1965).
6 According to Reich (1942/1973) physical stiffness is the most essential part of the repression process, and therefore, the clinical focus should changefrom the psychological and characterological exploration to the dissolutionof the "muscular armor". Such dissolution not only liberates vegetativeenergy, but also allows bringing to memory the repressed remembrancesand affects. Reich suggests penetrating directly towards the affects throughthe chronic muscular attitudes and tensions.
7 Pichon-Rivière (1970/2003) defines the emergent as one of the basic concepts in his theory on operative groups. The emergent is a representation or imagethat stems from the group process, and which has the capacity to explainand communicate what is implicit. When the emergent is correctlyinterpreted by the coordinator (analyst), the group is able to face what isunconsciously resisted.
8 Coming from a Lacanian theoretical framework, Arnaud (2002) emphasizes the relevance of analyzing organizations taking into account the symbolicorder that regulates the operation of their dynamics. This symbolic orderrepresents a "trans-subjective extraneous place" that pre-exists and is exter-nal to the individual subject (p. 700). The symbolic medium, that Lacancalls the "Other", can be embodied through intersubjective relations anddiscourses that "express, define, and sanction the conditions of possibilityof the subject" (p. 695). According to Arnaud, the symbolic circulates andis shared within groups and organizations, thus impacting heavily upon theirfunctioning and quality of performance.
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Matías Sanfuentes Business Department, University of Chile, Diagonal Paraguay 257 of 1106, Santiago 6330015, Chile Int. J. Appl. Psychoanal. Studies (2015) Copyright 2015 John Wiley & Sons, Ltd.

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HIV Services and QIPP Contents 1. Executive Summary What is ‘QIPP'? HIV Services – the current picture Outcomes – Developing measures that matter Treatment – Developing clinical and cost effective prescribing in the context of choice Care – Developing approaches to meet the needs of people living with HIV

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British Journal of Anaesthesia 96 (1): 8–20 (2006) Advance Access publication November 29, 2005 Fluid absorption in endoscopic surgery Department of Anaesthesia, Karolinska Institute, South Hospital, SE-118 83, Stockholm, Sweden Fluid absorption is an unpredictable complication of endoscopic surgery. Absorption of smallamounts of fluid (1–2 litre) occurs in 5–10% of patients undergoing transurethral prostaticresection and results in an easily overlooked mild transurethral resection (TUR) syndrome.Large-scale fluid absorption is rare but leads to symptoms severe enough to require intensivecare. Pathophysiological mechanisms consist of pharmacological effects of the irrigant solutes, thevolume effect of the irrigant water, dilutional hyponatraemia and brain oedema. Other less widelyknown factors include absolute losses of sodium by urinary excretion and morphological changesin the heart muscle, both of which promote a hypokinetic circulation. Studies in animals, volun-teers and patients show that irrigation with glycine solution should be avoided. Preventivemeasures, such as low-pressure irrigation, might reduce the extent of fluid absorption butdoes not eliminate this complication. Monitoring the extent of absorption during surgery allowscontrol of the fluid balance in the individual patient, but such monitoring is not used widely.However, the anaesthetist must be aware of the symptoms and be able to diagnose this com-plication. Treatment should be based on administration of hypertonic saline rather than ondiuretics. New techniques, such as bipolar resectoscopes and vaporizing instead of resectingtissue, result in a continuous change of the prerequisites for fluid absorption and its consequences.