Category Archives: ethical challenge

Ethical Dilemmas – when Doing Things Right is not Doing The Right Thing

Defunding the police is about “reallocating funds, shifting responsibility away from roles that police have absorbed over time, and establishing guidelines on what society wants and needs from police, including how the police are expected to act in our service.” The issue is not better adherence to policies and practices – doing things right, but greater focus on outcomes for society – doing the right thing.

This is the point made by Suzette Woodward in her book about implementing patient safety. Safety I is ‘the absence of failure’ to follow existing policies and practices, doing things right. Safety II includes Safety I but focuses on outcomes, doing the right thing:

“the ability to succeed under varying conditions so that the number of intended and acceptable outcomes is as high as possible” (p43)

Safety I is thus work-as-prescribed, seeking to limit how far work-as-done diverges from work-as-prescribed in order to prevent errors of execution. When these prescriptions extend to define rules governing composite work-behaviors, for example in combining different drug treatments, Safety I also covers the prevention of errors of planning. The underlying assumption here is that design-time and run-time can be separated, the times at which plans are formed and behaviors prescribed able to take place long before the run-time of work-as-done.[1]

Work-as-prescribed is when we set clear rules and detailed instructions for carrying out tasks […] when the gap between work-as-done and work-as-prescribed needs to be as narrow as it possibly can be.” (p68)

Safety II becomes necessary when this separation is no longer possible because of the dynamic and fluid nature of situations that change with each action.[2] The wicked nature of such situations makes planning impossible, concern with the static nature of errors of planning having to give way to the avoidance of dynamic errors of alignment in each moment[3] and of errors of intent through misreading the demands in each situation.[4]

An environment in which the focus must be on outcomes under dynamic and fluid conditions is turbulent. It requires that an organisation takes power to its edges to minimise both errors of alignment and errors of intent. Such environments require a Safety II focus of horizontal accountabilities to the situation of the client at an organisation’s edges. This creates a new kind of challenge in which obedience to work-as-prescribed is no longer sufficient to ensure safety. New kinds of obstacle to avoiding errors of alignment and intent arise from assumptions derived from obedience to vertically-defined work-as-imagined and built into a individuals’ ways of thinking implicit in work-as-disclosed:

“Work-as-imagined refers to the way people who regulate, inspect and design interventions don’t really understand what reality is actually like (p67) […] work-as-disclosed is how people describe what they do whether in writing or when they talk to each other… (p70)

These new kinds of obstacle may be thought of as a series of three tensions that have to be held.[5] Work-as-prescribed top-down by management is never wholly commensurable with work-as-experienced bottom-up by the individuals doing the work. The assumption with Safety I is that top-down dominates.

Work-as-disclosed reflects the way this first top-down vs bottom-up tension is currently held while always falling short of fully accounting for the unthought known of work-as-done. The second tension is thus between work-as-disclosed and work-as-done, reflecting the limited ability of people’s ways of thinking to capture all of what is going on.

The way this second espoused vs unthought-known tension is held takes the form of work-as-imagined. There will be many ways of holding this tension, but the dominant way shared within an organisation will be the one to which its members are affiliated, referred to as an organisation’s culture:

“… ‘the way we do things around here (when people aren’t looking)’ and the sum of attitudes, customs and beliefs that distinguishes one group of people from another.” (p117)

Safety II introduces a third tension because of the alliance it demands with the situation of the patient, a work-as-demanded that is rooted in what constitutes a desirable outcome for the client-patient. This is a tension between an affiliation to work-as-imagined and an alliance with the work-as-demanded. The way this third affiliation vs alliance tension gets held presents an ethical dilemma for the individual empowered to hold the tension at the edge of the organisation – a dilemma in how to hold the balance between the interests of the organisation and of the client-patient.

The following table summarises the progression of tensions that culminate in this ethical dilemma:

vswork-as-experienced bottom-up=work-as-disclosed espoused theory
2work-as-disclosed espoused theoryvswork-as-done unthought known=work-as-imagined affiliation
3work-as-imagined affiliationvswork-as-demanded alliance=ethical dilemma

Wynton Marsalis speaks of a segregation within the USA that reflects failures in how this third tension is held in the interests of all US citizens, an example of such a failure currently giving rise to the calls to defund the police. But why an ethical dilemma? Mark Ruffalo, speaking about using his celebrity, had this to say about putting himself on the line:

“We’re past the point where a celebrity can just make a video and tell people what to do … we’ve been doing that for decades. Now we have to put our bodies and our money and our time and our comfort on the line. That’s what’s being asked of us when we’re being asked to be allies.”[1]

Holding the third affiliation vs alliance tension means questioning our identifications with the citizen-client as distinct from our identification with the organisation, questioning who we take ourselves to be. Mark’s point was that to hold the third tension means being prepared to put ourselves on the line – to be prepared to pay with our being[6]. It also means questioning for what are we, as individuals, using organisations.


[1] The replacement of people by machines, or at least AI software, thus appears to some to be the ultimate guarantee of Safety I. The crash of Air France Flight 447 is one of many instances showing the limitations of such a guarantee.

[2] As the famous quotation goes: “No plan of operations extends with any certainty beyond the first contact with the main hostile force”.

[3] This involves deconflicting behaviors so that they can be mutually reinforcing of an overall desired effect, the other side of which is to ensure interoperability between capabilities in order to reduce the potential for errors of alignment.

[4] Working at the edge of an organisation in this way involves being able to attend to the ‘something missing‘ in the way the client’s situation is understood. A misreading arises when a blind eye is turned to this ‘something missing’. The plus-one process is designed to develop the skills of working at the edge.

[5] These three tensions are the dilemmas of ignorance applied to the way power is exercised within an organisation: top-down vs bottom-up; espoused theory vs unthought known; and affiliation vs alliance.

[6] The 2nd crisis in the three moments is to be unable to get any further with an existing way of thinking/understanding. The third moment comes when we choose to act as if we know while knowing that we do not. Such a choice involves letting go of existing identifications, i.e. to ‘pay with our being’.

The Ethic demanded is of Engendering Leadership

The presentation describing this pathway within the 3rd epoch domain explores what is the ethic underlying this way of approaching the relation of an organization to its wider ecosystem?

Under edge-driven competitive conditions, leadership must support a questioning both of the structures underlying the capabilities of the organisation and of individuals’ valencies for how they support value-creation.  For an organisation to be dynamically responsive to its clients in a way that is sustainable, this means balancing the consistency of each response to a client’s situation by an interest in its incompleteness.  Engendering leadership enables this balance to be held in its pursuit of learning.

There are a number of challenges that an organisation faces as it goes relational and becomes edge-driven. The challenges arise in seeking to create effects in clients’ situations that reduce clients’ value deficits while at the same time remaining sustainable as an organisation.  Foremost amongst these are the parallel processes that need to be sustained by governance structures rooted in an alliance with the client-in-their-situation. Another challenge is in overcoming the forces of maladaptation that stand in the way of such alliances. Going relational thus involves more than the Hippocratic Oath to ‘do no harm’.  It involves doing as much as possible for the client without jeopardising the sustainability of the organisation. A key question, then, is why individuals should choose to do this.

The earlier pathways have addressed this question in terms of the interests of organisations in supporting the changing competitive dynamics of ecosystems. But what do these changes demand of individuals working for and within organisations?  The temptation has been to encourage individuals to be dependent on the organisation to support their identities through the roles on offer.  While organisations these days make fewer and fewer long-term commitments to their employees, there is nevertheless still an implicit bias to do as much as possible for the identities of senior management and shareholders while not jeopardising the relationship to customers.  Overcoming this implicit bias involves a change in the kinds of identification that are supported, underpinned by individuals’ valency for particular ways of being. Going relational involves individuals developing a different relation to their valency.

Personal valency is rooted in the way an individual takes up a relation to what-is-going-on (wigo) that is also implicitly a relation to what remains lacking in that way of organising wigo. The individual experiences a value deficit just as much as does a client, so a choice between the interests of the employee and those of a client is a matter of balancing their respective interests. The point about going relational is that it is a response to a fundamental shift in how this balance must be held in creating value for the client.  To make sense of this, three layers need to be distinguished in the way an individual takes up a relation to wigo.  First there is the auto-noetic layer of conscious speaking about wigo. Second there is the noetic layer below the layer of consciousness that is implicit in the way the individuals’ behaviors are themselves a part of wigo.  A third a-noetic layer is then needed to give an account of an individual’s valency for the way their second noetic layer is organised. This a-noetic layer is radically unconscious in the sense of being unknowable in any direct way.

To understand this, it is easier to start from the way the relation to the client’s lack is held by the behaviors of an organisation.  There are thus real traces left by real objects, intentional traces arising from the way patterns of behaviour are experienced, and traces-of-absence arising from the way patterns of behaviour are experienced as not present.  These three kinds of trace define three separate kinds of surface, a primary task surface arising from behaviors, a domain of relevance surface arising from the way behaviors are experienced, and a primary risk surface arising from the way behaviors are not experienced.  An organisation is founded and subsequently develops by the way these three surfaces are held in relation to each other. In this sense, the organisation is this way of knotting the three surfaces together in the a-noetic layer.

These three surfaces come to be known only by the data in the second noetic layer arising from the way the individual pays attention. The valency of an organisation is thus the way this knotting is taken up by an individual in the second noetic layer as a way of realising their identification, complete with its implicit relation to lack.  Different kinds of identification thus create different kinds of strategy ceiling on the way behaviors are organised in relation to clients.

There are an equivalent three surfaces in the relation of an individual’s neural networks to their embodiment so that while there is a valency for the way an individual takes up their identification per se, there is also an implicit valency for the way an organisation provides support for the individual’s identification. The different ways in which this is done are then reflected in the different ways in which learning can take place.

There are then two sides to valency.  These need to be considered in order to return to the question of why individuals should choose to change the way in which they take up their identification. On one side is the consistency that is the way an identification is taken up, while on the other side is its incompleteness.  This incompleteness, experienced as a relation to an irritation of doubt, a value deficit, a structural lack, or a disrupting ‘Real’ identification, makes a radical non-rapport apparent between the current organisation of consistency and an ‘otherness’ that is quite other – an extimate symptom of lack.  Engendering leadership, then, is an approach to leadership that holds this non-rapport in order to create the conditions in which innovations, qua third moments, may emerge that can sustain learning and adaptation. Individuals should choose to change the way they take up their identification for the good in being alive to wigo as much as for the good of the larger ecosystem.

Working on the edges

by Philip Boxer
The following set of notes emerged from a conversation with Sandy Henderson about the forensic approach – an approach to understanding and beginning to address ‘systemic bias’.[1]

Implicit in the way a person speaks about what is going on (wigo) is a way of framing meaning. The frame contains wigo for the speaker in the sense of providing a way of giving meaning to their experience of wigo.[2] The wigo being contained needs to be distinguished here from the way wigo is held, which means to limit the granularity and detail of the phenomena that need containing.[3]

  • This way of framing rests on implicit assumptions that govern its reasoning.
  • The assumptions implicit within a frame can be reinforced by a cycle of process-outcome-consequence (a process undertaken to achieve an outcome has consequences that reinforce the frame’s way of containing wigo).
  • Outcomes are about what happens while consequences are about how those outcomes impact on the interests of those invested in the frame’s outcomes.
  • The frame can be disrupted by a consequence that cannot be contained by the frame’s implicit assumptions.
  • This disruptive consequence can ‘flip’ the person out of the frame into an ‘other’ frame resting on different implicit assumptions with its own reinforcing P-O-C cycle that is able to contain the disruptive consequence but in which interests are invested differently.

A dilemma emerges if the ‘other’ frame also encounters disrupting consequences such that the person is ‘flipped’ back to the P-O-C cycle under the previous frame, giving rise potentially to an oscillation between two frames.

  • When this happens, this oscillation takes place around a ‘gap’ representing the aspects of wigo that neither frame is able to contain.
  • Any frame is vulnerable to the possibility of being disrupted by ‘flipping’ outcome-consequences. There are thus always ‘other’ frames possible and different kinds of dilemma, therefore, each revealing gaps representing different kinds of impossibility.
  • The way this ‘gap’ is encountered (and the impossibility that it represents to either frame) will be symptomatic of the way each frame is being held in order to limit the disrupting consequences encountered by each of their P-O-C cycles.

Holding frames in a way that limits disrupting consequences creates a ‘systemic bias’[4] that is manifested in three ways:

  • The first is by a flight to the personal aka scapegoating – an explanation in terms of individuals’ responsibility that leaves the frames themselves unacknowledged.
  • The second is by turning a blind eye to granularity and detail that would make disrupting consequences apparent by insisting on an existing way of holding frames.
  • The third is by the disclusion of the interests of persons identified with consequences that would disrupt existing ways of holding and containing frames. To disclude is to exclude the interests of a person from consideration and dismiss as irrelevant any granularity and detail of wigo relating to those ‘other’ interests that could give rise to disrupting consequences.[5]
  • All of these manifestations of systemic bias provoke hostility and mistrust and create injustice for those affected. An injustice here means that interests are being served at others’ expense that are in some way unnecessary, excessive and/or unjustifiable.

Any challenge that is permitted to existing ways of holding frames could give rise to new frames and new kinds of gap. If a challenge is not permitted (intentionally or otherwise), the resulting injustice can be approached as a (serial) ‘murder’ of innovations – the potential frames whose creation is thereby prevented.[6]

  • Such murders may be ‘investigated’ by treating as ‘crime scenes’ the P-O-C cycles in which the injustices arose and identifying the means, opportunity and motive through which the ‘murders’ took place.
  • Probable cause aka ‘reasonable grounds’ for the systemic bias may be established by identifying the means, opportunity and motive for the scapegoating, turning a blind eye or disclusion.
  • Motive may be established through establishing the particular interests being served by the existing ways of holding frames. The systemic nature of the ‘murders’ may then be identified with those standing to benefit from them who have the means and opportunity.
  • For ‘probable cause’ to be established, however, we need ‘detectives’ – persons whose personal valency leads them to sense the injustices and to have the drive to do the forensic work involved.[7] The intention behind establishing ‘probable cause’ is, of course, a successful ‘prosecution’ that changes the repeated behaviors towards ‘others’.

The exploration of a situation felt to be problematic and/or unjust in some way – and an individual’s valency for recognising it – can be achieved through a way of using the ‘plus-one’ process. This sets out to look beyond the ‘truth’ of an individual’s narrative of a situation in order to uncover the dilemma they are experiencing in the situation, and to explore the nature of the gap between its frames with its underlying impossibility.

  • This plus-one process involves three people with a fourth person in a witness role. The plus-one process itself starts with a narrating of a situation by a speaker (1) to a listener (2) in the presence of a person in the plus-one role (3). The following three stages are repeated three times as the three people rotate around these three roles. The person in the witness role bears witness to the whole process of rotating roles.
    Stage 1 involves, in the first iteration, the articulation of the narrative about the situation experienced as problematic/unjust from the speaker’s perspective. Subsequent stage 1 narratives are in each case of a situation experienced by the speaker that shows the meaning of the metaphor they previously identified from their plus-one role.
    Stage 2 involves clarification of the narrative by the listener.
    Stage 3 is the production of a metaphor by the ‘plus-one’ based on a counter-transferential ‘hunch’ about the narrative framing within which the narrative unfolded as it emerged from the speaking-and-listening.
  • The metaphor represents the plus-one’s sense of the shape of the speaker’s relation to the situation that has emerged. The metaphor derives from the feelings evoked in the plus-one by the speaker’s articulation of the narrative and its subsequent clarification by the listener.

The witness will subsequently use the three metaphors that emerge from the plus-one process to hypothesise an ‘other side’ of the original narrative articulated by the speaker as a first step in formulating the gap between the two frames and the underlying impossibility it represents.

  • Having elaborated this ‘other side’ as an alternative P-O-C cycle narrating of the original situation, it needs to be validated by relating the ‘flipping’ consequences in each frame back to the original narrative and defining the oscillation between them.
  • The witness’s final step is then to hypothesise the nature of the gap between the frames and the underlying impossibility it represents.

Two questions then arise that define the focus of a Lacanese parallel process[8]: (i) what is it about the way this dilemma is being held that sets it up in this way; and (ii) what is the nature of the original speaker’s valency for this way of its being ‘set up’. [9]

[1] ‘systemic bias’ is apparent, for example, in institutional racism. I have written about ‘systemic bias’ in a number of its guises. In its extreme forms it edges over into being ‘white collar crime’. The forensic rule in these kinds of case is ‘to follow the money’:
“Defences against innovation: the conservation of vagueness.” (2014) Defences Against Anxiety: Explorations in a Paradigm. D. Armstrong and M. Rustin. London, Karnac: 70-87.
“Betraying the citizen: social defences against innovation.” (2015) Organisational & Social Dynamics 15(1): 1-19.
“Working forensically with toxic thinking: what doesn’t kill you makes you stronger.” (2015) 32nd Annual Meeting of the International Society for the Psychoanalytic Study of Organizations. Rome, Italy.
“Caring beyond reason: a question of ethics.” (2016) European Academy of Management Conference. Paris.
“On the betrayal of the other’s trauma: the ethics of questioning unconscious investment in turning a blind eye.” (2016) 33rd ISPSO Annual Symposium. Granada.
“Working with defences against innovation: the forensic challenge.” (2017) Organizational and Social Dynamics 17(1): 89-110.
[2] ‘Contains’ aka returns meaning, following Bion’s thinking about what transforms beta-elements to alpha-elements. Beta-elements are experienced as bizarre, provoking anxiety. To contain is therefore epistemic in its effects, transforming the bizarre into something that can be given meaning to. Meaning must nevertheless be understood as meaning ‘for me’, i.e. for the individual trying to make meaning.
[3] ‘Holding’ aka limiting the complexity and granularity of the phenomena being faced, following Winnicott. By granularity is meant the scale or scope of detail present in the phenomena. The way the child was held by the family situation protected the child from being exposed to phenomena that could be overwhelming or traumatic, inducing a fear of imminent annihilation.  To hold is therefore ontic in its effects, defining reality itself for the child in which the bizarre might occur. A useful account of the important role of ‘ontological scaffolding’ is to be found in Lane, D. A. and R. R. Maxfield (2005). “Ontological uncertainty and innovation.” Journal of Evolutionary Economics 15.
[4] ‘Systemic bias’ aka way of sustaining an identification of interests in the way the frame(s) produce outcomes, the consequences of which are reinforcing of those interests.
[5] To both dismiss and exclude is to disclude…  the exclusion limits the granularity and complexity of the phenomena under consideration, while the dismissal reflects the way of framing.
[6] I use ‘murder’ here because it leads us to the detective genre, which is a valuable metaphor for the thinking about the challenges of working forensically. Typically, the detective is having to be relentless in the pursuit of what happened while at the same time having to battle with forces of authority that want the case closed for other reasons. See also the use of this metaphor in dilemmas as drivers of change.
[7] A brief summary of the detective genre would start from the detective’s code: dedicated to the victim, economical if not thrifty in his or her expenses and personal habits, loyal to his or her profession, cooperative to some degree with the police, concerned with self-survival, and unwilling to be duped by anyone. I have written about forensic work in Boxer, P. J. (2017). “Working with defences against innovation: the forensic challenge.” Organizational and Social Dynamics 17(1): 89-110.
[8] Not to be confused with the Balint approach to shadow consulting, which corresponds more to the role of the plus-one.  This approach to parallel process is a further development aimed at tackling the ethical challenges inherent in the original situation.
[9] Of course taking up either of these questions implies addressing the other question in some way. This implies an ethic to the extent that it demands that a manager takes responsibility for his or her own valencies. This points towards a kind of Hippocratic oath for managers – to abstain from doing harm. It also links us back to understanding what is constitutive of unintentional errors.

The fourth dilemma: an ethics for the fourth estate?

by Philip Boxer
The need for asymmetric leadership arises when an enterprise must be dynamically responsive to its clients one-by-one in the way it supports a client’s experience. Examples would be providing a weather forecast for a particular operational mission, the health care of a patient with an ongoing condition, supporting a bank’s management of its capital adequacy within changing regulatory constraints, or providing multiple versions of a print newspaper for different readerships: {weather; healthcare; capital adequacy; news}.

A consequence is the need to move towards privileging the demands of a horizontal relationship to a singular demand, even though while remaining subject to constraints imposed by vertical accountability relationships. I have referred to this approach to governance elsewhere as an East-West dominant approach. In the example cases, this involves being able to dynamically align behaviors {forecasting; orchestrations of care pathways; risk exposure; print version} to the singular demand {mission profile;  patient’s condition; risk situation; community of interest}.  Inherent to this approach is the notion that the client’s demand is asymmetric to the supplier’s thinking, so that there is always a value deficit – a ‘more’ still to be addressed {the forecast is never wholly accurate; the condition is never fully understood; the information about the credit risk is always imperfect; the news always leaves the community of interest with unanswered questions}.

To think through what are the distinguishing characteristics of the ecosystem of organisations necessary to sustaining these forms of dynamic alignment, a fundamental distinction has to be made between the stratification needed to sustain responses to symmetric as distinct from asymmetric forms of demand. While the former strata must deliver economies of scale and scope, the latter strata must deliver economies of alignment. These strata are shown in the following in terms of strata 1-4 supporting symmetrically-defined market segments, and strata 5-6 addressing the orchestration and synchronisation of responses to asymmetric demands one-by-one:[1]

The squiggly line marks a fundamental tension between the supply-side orientation of maximising the value to be derived from ‘possible behaviors’ through creating economies of scale and scope (creating as much value as possible for the supplier without jeopardising the customer relationship); and the demand-side orientation of minimising the client’s value deficit through creating economies of alignment (creating as much value as possible for the client without jeopardising the sustainability of the supplier). Each ‘box’ represents a matrix. The relationships between these matrices reflect three asymmetries that have to be managed in bringing the supply-side into relation with the demand-side, depending on the nature of the relationship that suppliers take up to clients’ demands (and how much is left to clients):

  • 1st asymmetry: the technology (1) is not the product (2)
  • 2nd asymmetry: the business (3) is not the solution (4)
  • 3rd asymmetry: the client’s demand (5) is not the client’s experience (6)

Viewed from the perspective of an individual client, a business focused on minimising the client’s value deficit can never hope to provide all the supply-side solutions that have to be orchestrated and synchronised with the client’s situation – it takes an ecosystem of suppliers. A fourth asymmetry emerges, therefore, to the extent that the value deficit is to be minimised.[2] In the examples these would be the domains in which there was effective know-how capable of {forecasting in a dynamic complex adaptive weather system; intervening on the body’s dis-ease; analysing the dynamic interactions between a business model and its environments; editorialising content in relation to particular readers’ interests}.  This fourth asymmetry is that

  • what the client experiences is never all of what the client wants

Holding this fourth asymmetry[3] means empowering the edges of the organisation where this asymmetry is encountered.[4] This brings us to the question(ing) of an ethics for the fourth estate.

The fourth dilemma facing the fourth estate
Consider the fourth of our case examples.  Reporters are despatched into the field to assemble material that can generate news stories. These are orchestrated within an editorial narrative to be read by different communities of interest:

The fourth asymmetry is that whatever actually gets read is never the whole story – a gap is always left. So does the fourth estate pursue the gaps, or does it make do with what it can easily find from existing sources? This is the ethical question for the fourth estate – some would say its raison d’être in a democracy.  Returning to our examples, an ethical challenge can be identified in each case: {forecasting when lives are at stake; early diagnosis greatly improving future quality of life; the value is in enabling the client to sustain the indirect benefits of the investment; a lack of real understanding destroys the ability of citizens to hold others accountable}.

[1] These strata are explored in more detail in a series of postings linked to by the summary: So you say you want to put your clients first… These matrices represent possible behaviors. As is described in these postings, however, the actual behaviors are determined by ‘organisation’ imposed by people. In the diagram below, this organisation, which is constraining behavior in matrices 1-6, is shown as the ‘B’ matrices. The oval matrices represent the limiting behaviors (0) and dimensions of deficit (7):
Note how ‘possible behaviors’ are thus made subject to vertical accountabilities, while the experience of value deficits are subject to the way behaviors are horizontally linked to situation.  Giving priority to value deficits therefore involves some degree of surrendering sovereignty in the way vertical accountability is imposed.
[2] This means putting the ‘domain of relevance’ into question, questioning the nature of the private good being served by the relationship. See the concept of strategy ceiling.
[3] The organisation focused on this fourth asymmetry must adopt a tripartite approach to leadership, capable of holding this inevitable tensions between minimising the value deficit while still remaining a sustainable organisation:
[4] The concept of rings and wedges provides a way of thinking about how the supply-side and demand-side are held in relation to each other. The tripartite approach, taken in the example below from work on leadership qualities, involves leadership that can balance the vertical constraints of operational leadership with the horizontal outcomes demanded by Front-Line leadership:

The Governance of Specialist Care: a question of ethics?

by Philip Boxer BSc MBA PhD

This paper, presented at the OPUS 2014 Conference, describes a two-year intervention within an organization providing residential care for men and women with mental health disabilities. This intervention, in support of the CEO and senior management team, took place during the mid-90’s when the UK Government was engaged in de-institutionalisation, making the transition to Community Care and instituting internal market reforms. The intervention itself was concerned with supporting innovations in the way the work of the organization supported the lives of its residents. These innovations were necessary to the continuing viability of the organisation as a specialist care organisation.

The paper is written from the perspective of 20 years later, making it possible to contrast the hopes and aspirations of both the consultants and the client at the time of the intervention with what actually happened to the organisation subsequently. The paper describes the way the authorisation of the consultants was drawn from the consulting approach. It describes the orthogonality that this demanded of the consultants, through which underlying dilemmas could be surfaced about the nature of the client system’s work. Three issues emerged from the intervention that are addressed by the paper: firstly, the nature and complexity of the client system in its networked environment and the extent of the innovation that this demanded; secondly, the nature of the consulting approach involved in responding to this demand; and thirdly, the implications this approach had for the governance of the client system.

From the perspective of 20 years later, it is not a surprise that the social defences against anxiety won out over the desire for innovation. This gives rise to a fourth issue however: what change in the relationship to the unconscious was being expected of the governance of the client system, what kind of courage did this demand, and what were the unconscious dynamics underlying the Trustees’ refusal to innovate? The paper concludes by considering the nature of orthogonality and the change in the relationship to the unconscious that this demanded of the governance of the client system, a change that involved an ethics that could move from ‘defending against anxiety’ to ‘being true to desire’. The paper concludes by considering the implications these ethics have for a different kind of group relations experience that can explore the existential impact of such changes, so necessary in networked environments.

Minding the gap – three moments of time

by Philip Boxer

How do we engage, describe and work without boundaries? How do we move beyond the familiar BART (boundary, authority, role, task) view of systems? And what does it mean to take up a network approach to leadership? A recent Regional Meeting of ISPSO in London took up these questions in terms of the ‘network-coach’ discourse, based on Simon Western’s work on Coaching and Mentoring[1]. This work very usefully distinguishes four kinds of discourse about the nature of coaching and mentoring, based on his research. This led Simon to ask me to clarify three ‘moments’ of time[2] that, while potentially facing a person in any one of these discourses, become particularly critical in the network-coach discourse.

Three moments of time
I described my work with a CEO who started our work together by describing a particular challenge he faced: he could not fit what his not-for-profit did into the normal kinds of business planning framework – service products, markets, competitive strengths and weaknesses, 5-year cashflow prediction etc. The not-for-profit was providing intensive social care, operating in the gap between the social services provided by the UK Government and individuals’ and families’ needs.

  1. The challenge he faced was a crisis for him that had arisen because of the planning framework his Board had asked him to use, which had defined a first moment for him[3] but which had brought about this first crisis – what the not-for-profit was actually doing did not fit the normal kind of business planning framework.
  2. The second moment[4] involved us working together to understand what was different about the economics of his not-for-profit, about how it needed to be organised differently, and about the different kinds of relationship this demanded between its employees and those to whom it provided care.  The result was a business plan that was accepted by the Board to form the basis of the next 5 years’ work by the not-for-profit, but also a second crisis – something else was needed if the not-for-profit was to develop different ways of actually behaving, a something else that was beyond any business plan. This second crisis was one in which the existing approach faces an impossibility.[5]
  3. So with this second crisis came a crunch time.  Something new was needed in the way the CEO engaged with the employees of the not-for-profit.  As it turned out, this inaugurated a third moment[6] in which a whole new challenge emerged initiating a new cycle of work aimed at addressing this challenge, but it took courage for him to accept this new challenge and ‘own’ the need to take it up.

These three moments of time and the two crises that separate them can be summarised as follows:

  • 1st moment: Accepting the stated problem/challenge and hoping that the existing approach will work.
  • 1st Crisis: Realising that the existing approach will not work on its own.
  • 2nd moment: Getting to grips with the details of the particular situation and adapting the approach to try to make it work.
  • 2nd Crisis: Realising that there is a fundamental limitation to the way the approach can be made to work.
  • 3rd moment: The persons involved put themselves ‘on the line’ in some way in order to act from something new that has the possibility of addressing the gap that has emerged.

These moments of time form a cycle of learning that is only bearable if the gap can be acknowledged – not hidden behind ‘solutions’. So in this case, the CEO works with the knowledge that the gap will always be there however good the ‘solution’ appears to be, and that by remaining aware of this gap, he can work with it while looking for the next gap to appear, which in turn will need to be acknowledged and worked through.

Minding the gap
This relation to the gap is what underlies Simon’s network-coaching discourse – realising that we don’t have neat boundaries, authority, role and task, that there is always a gap, and that the network society we live and work in presents us with increasing connectivity that pushes not towards identifying authority vertically in roles, but towards addressing horizontal rhizome-like power, power that is everywhere and yet cannot be pinned down. Simon’s conclusion was that, at best, we can find quilting points[7] that can anchor our relation to these networks for long enough to enable us to make good-enough sense and to act – until the next gap appears.

More on the second crisis
Further insight into what is involved in ‘minding the gap’ may be gained by looking more closely at the second crisis. This second crisis, corresponding to the ‘nightmare’ stage in a narrative structure [8], is frequently where people stop. In effect, what has happened is that a person has come to the end of conscious reasoning and may even be perfectly aware that what they are continuing to do makes no sense. But something stops them from going further.

This the second crisis can itself be divided into three moments:

  1. It is as if a higher authority has said: “Stop. Go no further. Not another word. It’s just not possible to go any further, and you are going to have to make do with what you have.” This is like a first moment within this second crisis.
  2. If the person continues, by saying “yes, but look what is going on. Surely things can’t be left like this. There must be something more that can be done.” This time, the stunned response from the higher authority is: “What do you want? What do you expect of me? Who are you to expect more to be done. Don’t you see how much is being done already? Stop making problems.” This is the second moment in this second crisis.
  3. Now comes the crunch. If the person still continues to insist that it must be possible to do something, then the question asked of the person moves to being their own question: “what do I want? What am I prepared to do about this situation that feels so wrong. I am going to have to go beyond what I know here if I am to do something more.”[9] This is the third moment in this second crisis that leads directly into the third moment.

What does this say about the nature of the challenge faced in minding the gap? It is that this gap is experienced as a [small-d] desire to do more, to go beyond what is known in the service of doing something more. In lacanese, to ‘mind the gap’ in this sense is to take up the ethical imperative to be true to [big-D] Desire – an ethic that demands that the subject ‘pays with their being’ in the sense of putting themselves on the line in some way.[10]

[1] Coaching and Mentoring: A Critical Text (2012) Sage.
[2] These three moments of time are based on the three moments in Lacan, J. (2006 [1966]). Logical Time and the Assertion of Anticipated Certainty: A New Sophism. Écrits: The First Complete Edition in English. New York, W.W. Norton & Co.
[3] The instant of the glance, ibid. This is the idea that you should be able to understand just by looking.
[4] The time for understanding, ibid. This involves having to work things out by thinking things through. The reasoning depends on the framework within which it is done.
[5] For more on the challenges of surfacing the nature of this impossibility, see working on the edges.
[6] The moment to conclude, ibid. The third moment is the moment in which the ‘challenge of the case’ is taken up, a new challenge that demands that the person puts themselves ‘on-the-line’ by going beyond what they know in choosing to take up the new challenge in their behaviour.
[7] These points of anchorage are ‘points de capitons‘ in Lacanese.
[8] For more on this, see “Betraying the citizen: social defences against innovation.” (2015) Organisational & Social Dynamics 15(1): 1-19.
[9] See Meeting the Challenge of the Case (in Casemore et al (eds) 1994 “What Makes consultancy work – understanding the dynamics” South Bank University Press pp358-371), in which Barry Palmer and I explore the nature of this challenge through a series of workshops. The nature of this challenge is taken from D.W. Winnicott (1965) Training for Child Psychiatry in “The Maturational Processes and the Facilitating Environment”. Hogarth Press., in which Winnicott argues that, if the child is to be helped, someone must be prepared to go beyond what they know…
[10] The reasoning behind these three moments within the second crisis comes from a session given during the course of Lacan’s XXVI 1978-79 seminar series on 8th May by Alain Didier-Weil in “A new theory of the Superego”. Didier-Weil, A. (1979). Nouvelle théorie du Surmoi. Book XXVI – Topology and Time. J. Lacan. unpublished.

What makes leadership ‘asymmetric’?

by Philip Boxer BSc MBA PhD

The blog on Requisite Authority argues that Asymmetric Leadership becomes necessary when competing in the ‘red zone’ – the zone in which the enterprise must be dynamically responsive to its clients one-by-one. But what does this mean for a person in the leadership position?  The answer boils down to the pursuit of four agendas that have to be held in balance, a lack of balance between them (i.e. unequal attention to each) leading to the collapse of the whole leadership effort:[1,2]


  • North[3]: Hold the context and provide ‘top cover’ for all those working within the enterprise.  Sustain the steadiness of intent of the enterprise.
  • East[4]: Legitimise questioning in the name of what-the-client-wants, so that the enterprise never loses a sense of its ‘edge’. Allow the otherness of the client to lead you to what is needed in their situation.
  • South[5]: Ensure that the supporting resources and infrastructures are appropriately agile, so that it becomes practicable to take up the questioning and to do something effective in response.  Know where you are and what is possible.
  • West[6]: Make it in people’s interests to engage both with the questioning and with finding ways of responding effectively, which is both a matter of the way individuals benefit from their work and also a matter of enabling them to be equipped with the appropriate skills, knowledge and experience to act effectively. Enable people to align whatever is available from the South to the demands from the East within the context of the North.

What makes leadership asymmetric?  It is that its authority is derived from enabling the enterprise’s responses to each client situation to be appropriately aligned in each case, one-by-one.  Its authority is not derived from what is already-known by the enterprise  – that already-known, vested in the leader, rendering his or her leadership symmetric aka North South dominant.  An example of this is given in considering what makes practice-based commissioning difficult in practice.

[1] This notion of balance was based originally on The Book of Five Rings written by Shinmen Musashi in 1645 (Allison & Busby: London, 1974), and in particular its notion of the void: “By void I mean that which has no beginning and no end.  Attaining this principle means not attaining the principle. The Way of strategy is the Way of nature.  When you appreciate the power of nature, knowing the rhythm of any situation, you will be able to hit the enemy naturally and strike naturally”. For us, this “enemy” is that which prevents us from continuing to be dynamically responsive to the situation.
[2] What makes this balance so difficult is the very different nature of each of the four agendas. Thus on the one hand is the conveyance of a shared sense of what the enterprise is about (N), and the grounding of this in meeting the challenges of each client’s situation (E). But in order for HR policies and systems of accountability to support dynamic alignment (E), and in order for the enterprise’s resources and infrastructures to deliver requisite agility (S) a wholly different order of complexity and timescale have to be managed. Failing to balance the ‘relationships’ (NE) with the ‘engineering’ (SW) means a split between a NE espoused theory and a SW theory-in-use with fatal consequences for the development of the enterprise as a whole.  The nine varieties of ground provide a way of thinking about the different kinds of challenge leadership faces as the four agendas become unbalanced.
[3] Fire: “This book is about fighting.  The spirit of fire is fierce, whether the fire be small or big; and so it is in battles.  This is the steadiness of intent with which the client challenges are enabled to be met.
[4] Wind: “This book is not concerned with my Ichi school but with other schools of strategy.  By Wind I mean old traditions, present-day traditions, and family traditions of strategy… it is difficult to know yourself if you do not know others. To all Ways there are side-tracks.  If you study a Way daily, and your spirit diverges, you may think you are obeying a good Way but objectively it is not the true Way.  If you are following the true Way and diverge a little, this later will become a large divergence.”  This is the ability to recognise and respond to what is ‘other’ about the client situation that is expressing an unmet need.
[5] Ground: “It is difficult to realise the true Way just through sword-fencing.  Know the smallest things and the biggest things, the shallowest things and the deepest things.  As if it were a straight road mapped out on the ground…”. This is about knowing were you stand in all respects in being able to act effectively.
[6] Water: ‘With water as the basis, the spirit becomes like water.  Water adopts the shape of its receptacle, it is sometimes a trickle and sometimes a wild sea. ”  This is about neither the ‘organisation-in-the-mind’ nor the ‘world-in-the-mind’ being frozen, but being able to take up the shape of what is being faced.

The future work of ISPSO is the psychoanalytic study of organisations

by Philip Boxer BSc MBA PhD

At this 30th annual meeting of ISPSO[1], it is my view that if ISPSO ceased to exist, it would have to be re-invented. There is too much of a future work yet to be done in the psychoanalytic study of organisations.  We need to work with:

  1. the existential dimension of anxiety, in which the very foundations and efficacy of our mental models are being called into question;
  2. the leadership of organisations in turbulent highly-networked environments, enabling their organisations to innovate continuously in response to their customers one-by-one;
  3. the courage necessary to putting ourselves on the line in order to do this kind of work; and
  4. the future generations, for whom each one of us must find in ourselves a response to these challenges.

I say “a work” in the sense of a life’s work or oeuvre, through which a person struggles to realise something felt to be true that can never be fully realised. In what follows, I want to say why I think this, but first, what exactly do I understand as constituting psychoanalytic insight?

The fundamental insight of psychoanalysis, which I attribute to Freud’s original work, is that we human beings are doubly subjected. We are subjected to the way in which we are able to construct meaning, to structures of signification, and we are subjected to our unconscious. Freud understood, in living this double subjection, that we human beings experience ourselves as most ourselves as subjects of the unconscious: “wo Es war, soll Ich werden[2]. And what does it mean to be ‘subjected’?  In our interactions with a structure, we are subjected to the extent that it constrains the ways in which we are able to act.  It follows from this double subjection that we are ourselves always implicated in any study we undertake.

Starting from this fundamental insight, we can ask what kind of a work this means for us, and why in particular this work involves the psychoanalytic study of organisations. A preliminary glance at the programme for this year’s annual meeting provides some preliminary clues. Words appear such as ‘not belonging’, ‘perverse solutions’, ‘climate change’, ‘ideology’, ‘containment’, ‘virtual organisation’, ‘gender relations’ and ‘betrayal’. These words indicate experiences that take place within the context of organisations. The experiences, however articulated, are of persons as subjects of their unconscious, and the contexts of which they speak are structures of signification.

The relation to anxiety
Emery and Trist give an account of work with the top management of a business in the aerospace industry that had been the outcome of a merger [3,4]. They had been asked to intervene because the top management had proved itself unable to collaborate in determining how to respond to a change in the technology associated with jet engines. Emery and Trist established that there were no deep incompatibilities between top management, nor was there stubborn adherence to past loyalties. It was their view, rather, that top management needed to engage in a collective re-appreciation of the whole situation faced by their newly-merged business. The conclusion of Emery and Trist was that there had been a flight into the personal dynamics arising between the members of the top management group and that this flight was from existential anxiety. This flight from existential anxiety, also referred to as annihilation anxiety, was preventing the group from engaging in the innovation needed to the changed situation facing the business.

The members of the top management group were in roles defined within the context of their newly-merged business.  There is nothing easy about taking up a role within an organisation and the demands for performance in a role are ever increasing and ever changing. Existential anxiety arises in the face of the possibility that the organisation-as-context will cease to exist in its current form, as with the aerospace case. It arises when an individual has difficulty even envisioning how his or her role might change, let alone knowing how to engage with changed circumstances. It is not surprising that the inability of the top management group to collaborate was originally identified with their ability to take up and perform in their roles.

In the last 30 years, ISPSO has learned much about how to work with the anxiety that individuals experience in seeking to take up and perform in their roles. Amongst all this learning, the group relations experience stands out as providing a unique approach to enabling individuals to learn about the way they authorise themselves within such contexts [5].  The challenge they faced, nevertheless, concerned the very existence of their organisation and not their relationships within it.  These were the conditions in which their existential anxiety arose.

Thus while performance anxiety is experienced within a given organisation-as-context, existential anxiety arises in situations where that given context is no longer experienced as effective or where there is no longer a given context.

  • The challenge of adding ways of working with this existential dimension of anxiety is a future work for ISPSO.[6]

The object of study
A recent project in the UK’s National Health Service has been examining the way a person’s experience of the end of their life is supported. Developing ways of aligning its own and others’ services to the person and their family context was not only highly valued by that person and their family, but also proved to be much less costly overall. Another organisation managing risk for a European car rental business was able to identify each vehicle at risk from pan-European flooding and take steps to mitigate that risk in each case. Again, aligning mitigating activities in this way proved to be much less costly overall.  In both cases, the object of study moves from being an organisation per se to being the dynamic performance of an ecosystem – sometimes referred to as a complex adaptive (eco-)system – in which a key consideration becomes its economics.

We are all aware of the huge impact that information technologies are having on organisations and whole industries. In these examples, the key difference is in being able to align services to client-customers one-by-one in a way that is dynamic. ISPSO’s object of study has been ‘the’ organis-ation, but under these new conditions the object of study becomes the dynamic organis-ing of activities. This is the distinguishing characteristic of Emery and Trist’s turbulent (highly-networked) environment which is ‘alive’ [7]. Not only must individuals be concerned with taking up a role within an organisation, but they must also be concerned with how the organisation takes up a role in the life of its client-customers. The organisation has to be able to organise many different ways of responding to its client-customers at the same time, ways that are constantly changing.

Information technology may be used to fragment and control, but it may also be used to enable the dynamic alignment of activities to situation and context. Using technology in this way means extending our understanding of leadership to include both the means and the potential impact of dynamic organis-ing.

  • Extending our understanding of leadership to include both the means and the potential impact of dynamic organis-ing is a future work for ISPSO.[8]

Psychoanalytic study
Returning to the way in which the psychoanalytic insight means that we are ourselves implicated in any study we undertake, it follows that psychoanalytic study demands that we consider how who-we-take-ourselves-to-be affects the ways in which we give meaning to our experience. We are ourselves invested in anything we do so that we can ask how it is that we ‘pay’ when engaging in psychoanalytic study.

  • One way in which we pay is with our time. Those of us that are paid by our clients or universities to study may recover some of this cost to ourselves, although even then it is rarely for all of our time.
  • Another way in which we pay is with words. Words are the medium in which we make meaning and those of us who work as analysts or writers know what a work it is to make meaning in this way. Rarely do we get paid for our words.
  • A third way in which we pay, which is the way that is most particular to psychoanalytic study, is to pay with our being. Winnicott, in speaking about the challenge of a case, spoke of the need for at least one person to be prepared to go beyond what they knew in order to respond effectively to the client’s situation[9]. This ‘going beyond’ is to pay with our being by putting ourselves ‘on the line’ or ’at risk’.

With this notion of ‘paying with being’ we return to the challenges of existential anxiety and the psychoanalytic ethic implied by taking up this challenge.  More than anything else, however, it is this preparedness to ‘go beyond’ that brings us together as an ISPSO community.

  • To continue to take up this challenge to our being is a future work for ISPSO.[10]

Paying it forward
ISPSO would have to be re-invented because its future work needs us to work together in finding new ways to work with existential anxiety, new understandings of our object of study, and new ways of taking up the challenge of psychoanalytic study. But more than this, in paying with our being we are paying it forward.

  • Our future work is for future generations, a work in which we must find it in ourselves to innovate.

[1] The ‘ISPSO’ is The International Society for the Psychoanalytic Study of Organisations. This blog formed the basis for one side of a debate concerning the future work of ISPSO, held at the 30th Annual meeting of the Society at Oxford.  The other side of the debate as presented by Jim Krantz is here.
[2] Freud, S. (1964). New Introductory Lectures on Psycho-Analysis. The Standard Edition of the Complete Psychological Works of Sigmund Freud. J. Strachey, Hogarth Press. XXII.
[3] Emery, F. E. (1976). Searching for New Directions. New Ways for New Times. M. Emery. Canberra, Australia, Centre for Continuing Education, Australian National University.
[4] Trist, E. (1977). “A Concept of Organizational Ecology.” Australian Journal of Management 2(2): 161-176.
[5] I have written elsewhere about some of the challenges faced by this way of thinking, particularly with respect to boundaries, authority and containment.
[6] For one approach to this other axis of anxiety, see Harari, R. (2001). Lacan’s Seminar on “Anxiety”: An Introduction. New York, Other Press.
[7] Emery, F. E. and E. Trist (1965). “The Causal Texture of Organizational Environments.” Human Relations 18: 21-32.
[8] For more on the challenges to leadership in these environments, see leading organisations without boundaries and the related paper on engendering ‘boundary’ as the object of psychoanalytic study.
[9] Winnicott, D. W. (1965). Training in Child Psychiatry. The Maturational Processes and the Facilitating Environment, Hogarth.
[10] For a way of elaborating on this three-way distinction, see Lacan, J. (2006[1966]). The Direction of the Treatment and the Principles of Its Power. Écrits: The First Complete Edition in English. New York, W.W. Norton & Co: [489]585-[542]648.

Edge and edginess

by Philip Boxer

Collaboration involves working with experiences in groups.  As such, consideration can be given to basic assumption activity affecting the work of the group – the way our personal unconscious valencies affect the ways in which we work together.  In this context, we can think of edginess as being on a personal edge…  the angst associated with being beyond our own comfort zone.  On edge, perhaps!  But how does this relate to the “edge” in edge-driven collaboration?

The following triangle separates these two concepts: edginess can be experienced as much within the boundary/perimeter of the organization as at its edges.

The challenge in collaborative learning, however, is to be able to use the experience of edginess to tell us something about what is going on at the edge.

‘Unintentional’ errors and unconscious valencies

by Philip Boxer

How are we to know what constitutes an ‘unintentional’ error? I want to be able to identify ‘unintentional’ errors as errors of intent in order to be able to ask why a diagnostician can be rendered ‘blind’ to the actual nature of the situated condition before him. Is it because no-one can know what is wrong, given the current state of knowledge? Or is it because the diagnostician is blind to the possibility that his mental model is itself inadequate? To clarify this distinction, I start from James Reason’s work on understanding errors – ‘To Err is Human’[1].

Understanding ‘intentional’ errors[2]
James Reason defines an error as the failure of a planned sequence of mental or physical activities to achieve its intended outcome when these failures cannot be attributed to chance. As a cognitive psychologist, he distinguishes three things:

  • the mental model that frames the way the diagnostician makes sense of the situation (‘knowledge-based performance’);
  • some way in which the diagnostician uses this model to establish correspondence between a plan and the situation observed (‘rule-based performance’); and
  • some way in which the diagnostician uses this plan to define actions on the situation (‘execution-based performance’).

Both the “intended outcome” and the “planned sequence of activities” are constructs of this mental model, which corresponds to the diagnostician’s ‘way of making sense’. In these terms, therefore, there are three kinds of error corresponding, in reverse order, to errors of (1) execution, (2) planning and (3) intent:

  1. the way the actions prescribed by the diagnostician’s way of making sense may be put into practice wrongly (‘execution-based performance’),
  2. the way the model is used to ‘make sense’ of the situation may be at fault (‘rule-based performance’), and
  3. the mental model may itself be unable to make the situation tractable (‘knowledge-based performance’).

According to Reason, however, error is not meaningful without the consideration of intent. That is, it has no meaning when applied to unintentional behaviors because errors depend on two kinds of failure, either actions do not go as intended (i.e. an error of execution) or the intended action is not the correct one (i.e. an error of planning). In the first kind of failure, the desired outcome may or may not be achieved; in the second kind of failure, the desired outcome cannot be achieved. For Reason, “intentional” errors thus reduce to errors of planning or execution, so if we follow him in restricting ourselves to ‘intentional’ errors, there are only errors of planning and execution. This is why errors of intent are not addressed in ‘To Err is Human’.[2]

Understanding ‘unintentional errors’
Reason nevertheless differentiates between slips or lapses and mistakes. A slip or lapse occurs when the action conducted is not what was intended.[3] It is an error of execution. In contrast, a mistake occurs when the action proceeds as planned but fails to achieve its intended outcome because the planned action was wrong.[4] It is an error of planning. On the other hand, a mistake in medicine might involve selecting the wrong drug because the diagnosis is wrong. In this case, the situation itself was mis-assessed resulting in the action planned being wrong (unless serendipitously right!).

From the patient’s perspective, not only should a medical intervention proceed properly and safely (i.e. free of errors of planning and execution), but it should also be the correct intervention for their condition in their particular circumstances. We are thus adding that the condition should itself have been correctly identified (i.e. the medical intervention should be free of errors of intent, such errors arising through the adoption of an unwanted aim).

The question here is why the condition itself should have been incorrectly identified, leading to the adoption of an unwanted plan. For Reason, a further distinction is made between mistakes at the level of applying rules and applying knowledge (e.g. ‘Human Error’[1] p56). Reason suggests that this distinction reflects two kinds of error: (i) because the situation was assessed incorrectly; and (ii) because of a lack of knowledge of the situation. In the first case we can agree that this is an error of planning. We would say that the situation was assessed incorrectly in the way the diagnostician ‘read’ the situation using his mental model. But in the second case we must ask what is meant by “lack of knowledge of the situation”. If this were “knowledge” in the terms of knowledge that the mental model uses, then it is the same as (i). But if not this, then it must mean that the existing unconscious mental model leaves the diagnostician ignorant of some aspects of the situation because it has no place for them. In the physical sciences, this would be like using Newtonian mechanics to predict the motion of electrons subject to quantum effects. In order to understand ‘unintentional’ errors, therefore, we need to consider the reasons for the inadequacy of the unconscious mental model being used.

‘Unintentional’ errors as evidencing unconscious valencies[5]
A theory of the subject would have to give an account of the subject’s conscious mental model of his or her world and its trajectories, to which the subject experienced himself or herself as being subjected.[6] But it would also have to give an account of the way in which the subject experienced himself or herself as being subjected to his or her unconscious mental model.[7] These two forms of subjection together constitute a ‘double subjection’, in which the concept of ‘valency’ provides a way of referring to an unconscious investment in particular ways of organising the subject’s conscious mental model of his or her world, i.e. in particular ways in which the conscious and the unconscious are held in relation to each other.

Using the concepts of double subjection and valency, we can now account for all three kinds of error as follows. The subject’s conscious mental model and its trajectories are the diagnostician’s ‘way of making sense’, from which ‘plans’ associated with ‘intended outcomes’ and ‘planned sequences of activities’ may be derived. The third kind of error of intent arises from the nature of the subject’s unconscious valency for particular kinds of ways of making sense because of the ways in which they support the subject’s identifications:

  • Type I: correspondence error, in which the subject’s conscious mental models fail to anticipate the subject’s experience in a given situation (i.e. an error of execution creates a correspondence error);
  • Type II: coherence/inconsistency error, in which an elaboration of the subject’s conscious model with respect to the situation renders the model itself incoherent through its inconsistency with the subject’s unconscious experience. The occurrence of such an error can be said to be a ‘signal’ to the subject of the need to change his or her conscious model but, in general, the error does not determine a suitable elaboration, or even guarantee that one may be found. (i.e. the way the subject’s conscious model is put into relation with the situation creates an error of planning, which reveals the incoherence/inconsistency of the model itself with respect to the situation);
  • Type III: decidability error, in which the subject faces more than one possible elaboration of his or her conscious model of the situation because the model is non-deterministic with respect to the situation, generating mutually inconsistent models from which to choose. This undecidability means that no diagnosis can in fact be made with the available model, making problematic its use in any choosing ‘what to do’.  Under these conditions, for the subject to act ‘as if’ he or she knows ‘what to do’ will be because of his or her valency to that course of action (i.e. acting from unconscious valency to a particular course of action in the face of such undecidability creates in an error of intent).

The implications?
The report following ‘To Err is Human’[2] was on the Quality of Health Care in America project[8]. It considered a range of quality issues related to the overuse, underuse and misuse of treatments.[9] If we are not to question the motives of doctors (i.e. as intentionally following forms of diagnosis that serve their own interests while not serving the interests of their patients), then overuse (e.g. operating on knees unnecessarily) and underuse (e.g. not prescribing a prophylactic orthotic treatment where it could mitigate future conditions such as the need for an operation) should both be considered as arising from errors of intent.

Understood in these terms, it is necessary but not sufficient, in order to address issues of quality, to seek to ensure the use of the best possible conscious models (e.g. through relying on the influence of ‘evidence-based’ forms of research).  The subject must also be prepared to take up the ethical challenge of questioning his or her unconscious investment in his or her particular ways of knowing i.e. questioning being subject to an unconscious model that is inadequate because of what it is structurally ‘blind’ to/lacks[10]. The process by which this ‘blindness’ can be worked with involve triple-loop learning, making use of reflexive processes.

[1] Reason, James, Human Error, Cambridge: Cambridge University Press, 1990.
[2] This section uses extracts from “To Err is Human: Building a Safer Health System”, Institute of Medicine, National Academy Press 1999. Pp46-47. This blog was provoked by the fact that errors of intent were absent from the analysis.
[3] The difference between a slip and a lapse is that a slip is observable and a lapse is not. For example, turning the wrong knob on a piece of equipment would be a slip; not being able to recall something from memory is a lapse. These are errors of commission or omission in the way the plan (of intended actions) is translated into practice.
[4] In medicine, slips, lapses, and mistakes are all serious and can potentially harm patients. For example, in medicine, a slip might be involved if the physician chooses an appropriate medication, writes 10 mg when the intention was to write 1 mg. The original intention is correct (the correct medication was chosen given the patient’s condition), but the action did not proceed as planned. If the terms “slip” and “mistake” are used, it is important not to equate slip with “minor.” Patients can die from slips as well as mistakes.
[5] Extracts drawn from Philip Boxer and Bernie Cohen, ‘Doing Time: The Emergence of Irreversibility’, Annals of the New York Academy of Sciences 901:13-25, 2000; and Boxer, P.J. and Cohen, B. (1997) “Analyzing the lack of Demand Organization”, 1st International Conference on Computing Anticipatory Systems, Liege.
[6] In psychoanalytic terms, this would be subjection to a ‘reality principle’.
[7] In psychoanalytic terms, this would be subjection to a ‘pleasure principle’.
[8] Chassin, Mark R., Galvin, Robert W., and the National Roundtable on Health Care Quality. The Urgent Need to Improve Health Care Quality, JAMA, 280(11):1000–1005, 1998.
[9] The impact of underuse, overuse and misuse on these issues was later published in ‘Crossing the Quality Chasm’: Committee on Quality of Health Care in America (2001). Crossing the Quality Chasm: A New Health System for the 21st Century, National Academy Press.
[10] The process by which the subject ‘conceals’ this structural blindness is through conserving forms of vagueness in in the way he or she applies his or her models.