Negative Capability and the Capacity to Think in the Present Moment: Some Implications for Leadership Practice

Two themes that are prevalent in the literature on leadership practice are planning for the future and learning from the past. In this ‘Leading Questions’ piece, we raise the question of whether, in addition, attention needs to be given to a third element that is not well represented in the literature: the leader's capacity to think in the present. We suggest that such thinking requires the capacity to see what is actually going on, in contrast with what was planned for, expected or intended – even when what is actually going on is uncertain or even unknown. In keeping with the theme of this special issue we demonstrate that attending to the present moment is a refrain both ancient and modern, to be found in eastern and western religion and philosophy while having a direct impact on practical modern disciplines, such as psychoanalysis. For example, Wilfred Bion's writings on psychoanalytic theory explore the nature of mental and emotional capacities demanded by this focus on the present moment and its relationship to the development of thought. Using an idea employed by Bion in this context, we suggest that an important dimension of leadership practice is negative capability, which comprises patience and the ability to tolerate frustration and anxiety. This capability can help the leader to retain the capacity to think in the present moment, even in the face of uncertainty. In this context, important dimensions of leadership practice include the ability to embody key thoughts on behalf of an organization and the capacity to contain the impact of the new thinking that can arise in the present moment. © 2011, Sage Publications. All rights reserved

A qualitative study of speaking out about patient safety concerns in intensive care units

Much policy focus has been afforded to the role of “whistleblowers” in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 h of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), we studied how personnel gave voice to concerns about patient safety or poor practice. We observed much low-level social control occurring as part of day-to-day functioning on the wards, with challenges and sanctions routinely used in an effort to prevent or address mistakes and norm violations. Pre-emptions were used to intervene when patients were at immediate risk, and included strategies such as gentle reminders, use of humour, and sharp words. Corrective interventions included education and evidence-based arguments, while sanctions that were applied when it appeared that a breach of safety had occurred included “quiet words”, bantering, public exposure or humiliation, scoldings and brutal reprimands. These forms of social control generally functioned effectively to maintain safe practice. However, they were not consistently effective, and sometimes risked reinforcing norms and idiosyncratic behaviours that were not necessarily aligned with goals of patient safety and high-quality healthcare. Further, making challenges across professional boundaries or hierarchies was sometimes problematic. Our findings suggest that an emphasis on formal reporting or communication training as the solution to giving voice to safety concerns is simplistic; a more sophisticated understanding of social control is needed.This study was funded by the Health Foundation, charity number 286967, and by Mary Dixon-Woods' Wellcome Trust Senior Investigator Award (WT097899)

Relational trauma and its impact on late-adopted children

This paper describes work with two children, placed for late adoption who have suffered relational trauma. The paper explores the long-term consequences of such trauma, which includes problems with affect regulation, difficulties in generalising from one experience to another and shifts between phantasies of omnipotent control and sudden helplessness. Using drawings from one boy's therapy, it is argued that many children adopted at a later age live in two worlds, both internal and external, and internal objects and memories from the past vie with new experiences and representations for ascendancy within the child's mind. Which is more real: the world of the past or the present? The paper describes how these children experienced sudden and troubling shifts in focus as they were catapulted from feeling states belonging to one world to the other. The paper ends with a consideration of how findings from neuroscience may help us to understand these sudden shifts and overall argues for a pulling together of psychoanalytic thinking and child development research findings to support the child in psychotherapy

A psychoanalytic concept illustrated: Will, must, may, can — revisiting the survival function of primitive omnipotence

The author explores the linear thread connecting the theory of Freud and Klein, in terms of the central significance of the duality of the life and death instinct and the capacity of the ego to tolerate contact with internal and external reality. Theoretical questions raised by later authors, informed by clinical work with children who have suffered deprivation and trauma in infancy, are then considered. Theoretical ideas are illustrated with reference to observational material of a little boy who suffered deprivation and trauma in infancy. He was first observed in the middle of his first year of life while he was living in foster care, and then later at the age of two years and three months, when he had been living with his adoptive parents for more than a year

Judgements of Solomon: anxieties and defences of social workers involved in care proceedings

Evidence from focus group discussions with social workers in child care and child protection was collected for a research project exploring decision-making in care proceedings and seeking a better understanding of the causes of delay in the process. Here this material is used to examine social workers’ feelings about their work and to explore the anxieties they expressed. Isabel Menzies’s work on containing anxiety in institutions is used to provide a conceptual framework for thinking about the ways in which individuals’ unconscious defences against anxiety may affect the structure, policies and practices of the organization in which they work. It is suggested that this dimension needs to be taken into account in understanding difficulties which arise in putting policy into practice

Beta-glucan reflects liver injury after preservation and transplantation in dogs.

Graft failure and extrahepatic organ complications, which frequently develop after transplantation, may be related to inflammatory mediators stimulated by endotoxin (ET). The role of endotoxemia after liver transplantation is controversial and may depend upon differences in the ET assay method used in the various contradicting studies. While the standard Limulus amebocyte lysate (LAL) is reactive for ET and beta-glucan, a novel turbidimetric assay method enables separate determinations of ET and beta-glucan. Beagle dogs undergoing orthotopic liver transplantation were divided into two groups. In Group I (n = 6) the grafts were transplanted immediately and in Group II (n = 6) grafts were preserved for 48 h in University of Wisconsin (UW) solution. Animals received cyclosporine immunosuppression and were followed for 14 days. Daily measurements of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) were performed. Samples for ET and beta-glucan measurement were collected serially and processed using the turbidimetric assay method. While no graft failure was seen in Group I, three of six Group II animals died from graft failure within 1 day after transplantation. Preservation and reperfusion injury was much more severe in the Group II grafts than in Group I grafts. While endotoxemia could not be detected, postoperative beta-glucan levels (undetectable pretransplant) were seen in both groups. Beta-glucan levels were much higher in Group II grafts than in Group I grafts, and correlated with the severity of liver damage. In conclusion, this study shows that beta-glucan, instead of ET, appears during the early posttransplant period. We believe that posttransplant elevation of beta-glucan is related to liver damage, especially endothelial damage by preservation and reperfusion

Object Relations in the Museum: A Psychosocial Perspective

This article theorises museum engagement from a psychosocial perspective. With the aid of selected concepts from object relations theory, it explains how the museum visitor can establish a personal relation to museum objects, making use of them as an ‘aesthetic third’ to symbolise experience. Since such objects are at the same time cultural resources, interacting with them helps the individual to feel part of a shared culture. The article elaborates an example drawn from a research project that aimed to make museum collections available to people with physical and mental health problems. It draws on the work of the British psychoanalysts Donald Winnicott and Wilfred Bion to explain the salience of the concepts of object use, potential space, containment and reverie within a museum context. It also refers to the work of the contemporary psychoanalyst Christopher Bollas on how objects can become evocative for individuals both by virtue of their intrinsic qualities and by the way they are used to express personal idiom

‘Stumbling through’? Relationship-based social work practice in austere times

In recent times relationship-based practice has become a familiar term in social work practice and education. Despite its widespread adoption, how relationship-based practice is understood varies widely. Drawing on contemporary conceptualisations of the child and family and individuals as psychosocial subjects experiencing social suffering, this paper explores how current social work practice can be understood in the context of neoliberalism and austerity. Setting these ideas in an historical context helps to inform our understanding as to why social work seems to be the focus of sustained political discontent and scrutiny, making it difficult to retain a balanced relationship-based professional stance. Contemporary responses to the current challenges of everyday practice are outlined and the contribution of psychodynamic and systemic ideas to promoting relationship-based practice is explored. The paper concludes by considering how the concept of social systems as defences against anxiety can inform our understanding of the resistance amongst practitioners to relationship-based practice and emphasises the importance of reflective spaces and places for developing and maintaining integrated, mature relational approaches to practice which impact on practice at both the individual casework and social structural level

Derivation and validation of a prognostic model for postoperative risk stratification of critically ill patients with faecal peritonitis

Background Prognostic scores and models of illness severity are useful both clinically and for research. The aim of this study was to develop two prognostic models for the prediction of long-term (6 months) and 28-day mortality of postoperative critically ill patients with faecal peritonitis (FP). Methods Patients admitted to intensive care units with faecal peritonitis and recruited to the European GenOSept study were divided into a derivation and a geographical validation subset; patients subsequently recruited to the UK GAinS study were used for temporal validation. Using all 50 clinical and laboratory variables available on day 1 of critical care admission, Cox proportional hazards regression was fitted to select variables for inclusion in two prognostic models, using stepwise selection and nonparametric bootstrapping sampling techniques. Using Area under the receiver operating characteristic curve (AuROC) analysis, the performance of the models was compared to SOFA and APACHE II. Results Five variables (age, SOFA score, lowest temperature, highest heart rate, haematocrit) were entered into the prognostic models. The discriminatory performance of the 6-month prognostic model yielded an AuROC 0.81 (95% CI 0.76–0.86), 0.73 (95% CI 0.69–0.78) and 0.76 (95% CI 0.69–0.83) for the derivation, geographic and temporal external validation cohorts, respectively. The 28-day prognostic tool yielded an AuROC 0.82 (95% CI 0.77–0.88), 0.75 (95% CI 0.69–0.80) and 0.79 (95% CI 0.71–0.87) for the same cohorts. These AuROCs appeared consistently superior to those obtained with the SOFA and APACHE II scores alone. Conclusions The two prognostic models developed for 6-month and 28-day mortality prediction in critically ill septic patients with FP, in the postoperative phase, enhanced the day one SOFA score’s predictive utility by adding a few key variables: age, lowest recorded temperature, highest recorded heart rate and haematocrit. External validation of their predictive capability in larger cohorts is needed, before introduction of the proposed scores into clinical practice to inform decision making and the design of clinical trials