Rationality without reason and the aetiology of mental illness

For over three centuries we, in Western societies, have lived in an Age of Reason. The accepted wisdom isthat decision-making must be a purely rational process devoid of emotion and underpinned by objective knowledge. This article draws attention to the invasion of human affairs by an ideology which makes deliberate use of one kind of rationality to the exclusion of all others. Changes In work and its organisation have been particularly driven by economic rationality which allows no thought for the effects on individuals. The clinical evidence centres around four specific cases which are presented against a background of the business practices current in the control of work. It is argued that these have a deleterious effect on mental health, especially for those psychologically disposed to respond faithfully to management calls for greater teamwork and commitment. thoughts

The thoughts expressed in this article were triggered by a small series of four cases which presented at clinics in which the author partici pated as a trainee in psychiatry. The cases occurred over a one-year period and all had in common that the patients were in business concerns which were reorganising. Perhaps these cases were more significant to the author because of his past management background, but there seems good evidence of a growing general concern about increasing stress at work particularly since a senior social worker, John Walker, successfully sued his employers for causing a 'nervous break down' (West, 1995). Even closer to home was the settlement of a similar claim out of court in favour of a junior doctor, Chris Johnstone (BMJ, 1995). The interest generated because of the financial implications of these last two legal cases is particularly ironic in the context of this paper.
It is also worth noting that the possible association between mental illness and the nature of work has been questioned before, specifically in the Presidential address to the Medico-Psycholo gical Society in 1875. James Duncan highlighted the apparent rise in the incidence of mental disorder and suggested changes in society wrought by the Industrial Revolution as an explanation for the increase (Healy, 1991).
This case series offers empirical, qualitative evidence of the damage done to individuals who have previously done their best, with some success, to conform to the demands of work in large organisations. They represent the losers in the political game of organisational change being played out at all levels in contemporary society.

Clinical features
Each one of the patients presented to general adult psychiatric clinics after several months of symptoms and all were described as depressed by their general practitioners (GPs). All were men aged in their forties who had been with their particular (medium to large) firms for at least five years, two having more than 20 years' service. At the initial interview two were still employed and two had recently accepted redundancy. Three had supportive spouses with no other major life events causing difficulties. The most seriously ill man also had relationship problems and a recent bereavement.
Only one had a family history of depression (a sibling) and all had notably successful early careers in which they demonstrated qualities of loyalty, reliability and conscientiousness accord ing to their own accounts and the evidence of their previous promotions. None had any significant previous illnesses entailing loss of work. One man had been educated to degree level and all had undertaken various vocationally orientated quali fications by way of self-development. Premorbid personalities did not seem to contain any traits which might make these people more susceptible than others to stress, except for the fact that they had generally been used to a certain amount of achievement. It might be argued that a desire to ensure that a job is done well is a mildly obsessive trait. If so, the current managerial efforts to focus attention on 'quality' may select a workforce vulnerable to stress when reorganisation occurs.
In addition to loss of energy and motivation (particularly while at work for the two still there), all patients showed sleep disturbance, with initial insomnia being more marked than early waken ing. The sleep problem was cited by all as due to intrusive thoughts regarding past conversations with, or actions of, senior managers. Loss of appetite was general but not to the extent of causing more than five kilos of weight loss.
The most severely affected man had continued working although he had been actively contem plating suicide for several weeks before referral. He had failed to secure one of the few positions commensurate with his previous status when a layer of middle management was removed from his firm. He had effectively been reduced to the ranks, albeit on protected salary. He declared that the future was a complete void because he had always seen his own fortune as intimately tied to that of his firm. He required considerable persuasion before agreeing to enter hospital voluntarily where he remained a suicide risk for several weeks. The two redundant workers confessed to regular vague suicidal thoughts which they were able to counter with anger: along the lines of not allowing their erstwhile bosses to have the satisfaction of totally disposing of them.
Anger was the dominant emotion in all pa tients, even for the man who was hospitalised who otherwise complained of lack of any emo tional feeling. It took a little time to elicit this in detail because of the shame felt by them at not having any control over events, when previously they had seemed so successful. The exception to this was in the case of the youngest man (age 41) who unleashed torrents of vituperation against his well-known high street firm almost as soon as he entered the consulting room. He was especially eloquent about the unethical behaviour of senior management in extinguishing even well argued and sensible objections to their planned changes. So great was his antipathy to the organisation that he had begun to avoid going into town so that he was not faced with seeing the corporate logo which induced stomach churning, palpitations and dizziness. His wife had to screen his post to remove all 'junk mail' which might also carry this emblem. Despite his disgust at the management, his was the only firm to attempt to assist in defusing the situation. Probably as a conse quence, he made the best recovery with only supportive psychotherapy and is now training (with out-placement funding) as a stress coun sellor.
The others talk freely now of how their selfesteem has been damaged and of how they were 'mugs' to have worked for so long and so hard for unfeeling institutions which professed to regard their staff as their greatest asset. One of the redundant men talked of his bewilderment that this should have happened to him, he who was easily the most flexible and committed of his work group. The very fact that the others took whatever liberties they could get away with and viewed events with a typical 'us and them' attitude seemed to protect them. They, to whom he had felt superior, were now largely survivors and so made him doubly distressed.

The wider context
The recent experiences of National Health Service professionals in terms of organisational upheaval may allow some empathy with patients suffering from stresses induced by similar change. In order for doctors to understand why this is an endemic problem in late 20th century society It Is necessary to appreciate the rise to dominance of a specific set of ideas. In one phrase these may be termed 'Rational Economies' which prizes pro ductivity, achieved through ever increasing effi ciency, effectiveness and economy, to the exclusion of every other consideration.
A cardinal feature of the Industrial Revolution was the 'Division of Labour', lauded by Prince Albert at a Mansion House banquet in 1850 as "The moving power of civilisation (which) is being extended to all branches of science, industry and art" (Golby, 1986). Albert meant that increasing specialisation provided more widely available knowledge to apply to the production process. It came to mean the reduction of skilled work to its component parts to allow increased mechanisa tion. The dehumanisation of work and the increasing requirement for people to fit the demands of machines became a societal norm. Indeed, the discipline imposed by the need to tend machines at specific times and in specific places is so ingrained that precise timekeeping is now a self-evident virtue for the world of work.
At the same time as workers were learning to become more robot-like, so the control of work, the management process, was striving to match the cultural requirement for all activities to become more scientific. The Holy Grail being sought was the one best way to deal with people to make them produce more for as little as possible. Of course, the one best way is probably through fear but that may not be thought quite ethical unless it can be concealed by some sort of rationalisation.
Rationalisation has been achieved by convin cing people that the overriding importance of 'the bottom line' of the balance sheet is axiomatic. The situation has been attacked by Critical theorists who highlight the selective use of reason to bolster particular vested interests against social justice (Habermas, 1984). Even writers within the business world state: "The exclusively analytic approach run wild leads to an abstract, heartless philosophy" (Peters & Waterman, 1982). Friedmanite monetarism has been questioned in standard business school texts, such as in comments that the relentless pursuit of economic goals leads to economic morality, but that this amounts to a social immorality (Mintzberg, 1991).
Occupational psychologists have given a great deal of attention to methods of harnessing individual aspirations and creativity to corporate purposes. Starting from investigations into the causes of monotony and fatigue at work, they considered job rotation, methods of payment, social groups, and hours of work as appropriate experimental variables (Burrell & Morgan, 1979). In the 1950s, Maslow's 'hierarchy of needs' seemed to offer a theoretical framework to explain some of the mass of data. The notion of work being the main route to 'self-actualisation' (the top of the hierarchy) is the invention of a management 'guru', Frederick Hertzberg. Since then, two generations of managers have been educated to think that enhancing the quality of working life was the modern way to increase productivity by avoiding worker dissatisfaction. So methods of enhancing the psychological contract between employer and employee have been the order of the day even before the advent of the new discipline of human resource manage ment (Walton, 1985).
Unfortunately, there are 'hard' and 'soft' ver sions of human resource management (Storey, 1991) and the quantitative, calculative, strategi cally impersonal, hard variant is in the ascen dant. The vocabulary is still full of people-centred phrases but the issues are all about controlling the costs of such expensive and often behaviourally irrational items. In what corporate planners are pleased to call the 'real' world, competition is everything and sifts out the winners and the losers. The point of the title of this article is that the rationality operated by the agents of institu tions -their senior managements -can be com pletely unreasonable from the point of view of individuals who might be inconveniently in the way of corporate progress.
It may have been always thus, but financially driven reorganisations with delayering and lim ited availability of remaining posts strikes parti cularly at those previously most committed to their institution. It must be hard to have one's self image as a person of some standing in the firm completely destroyed. An idea of how hard is outlined in the cases presented here. Four selected cases in one clinic in rural Wales suggests that a quantitative study in an indus trial area might yield a considerable number of people made ill by this particular aspect of the march of progress. As an economist, J. M. Keynes, was making a prescient psychiatric observation when he remarked that the work of a fellow economist "is an extraordinary example of how, starting with a mistake, a remorseless logician can end up in Bedlam" (Campbell, 1987).
Currently, Great Britain pic. is endeavouring to 'modernise' (reorganise along lines which make sense economically) to meet the competition from terrifyingly efficient organisations abroad. Large enterprises, including government departments and institutions, are undergoing huge changes driven by an ideological faith in market forces. Adam Smith's invisible hand will make it all come right in the end so long as we all become 'internal customers', 'product focused' and aware that there is no such thing any more as a conventional career. Flexibility, adaptability and eventually uncomplaining disposability are the necessary requirements for a successful national workforce.

Conclusion
If economic costs are the final arbiter of decisions made in boardrooms across the nation then it is important that the true costs of our current obsession with productivity are made known. Along the lines of'the polluter pays', and in purely economic terms, it is notionally possible to charge firms with the costs of having significant numbers of people in a state of cognitive dissonance (Festinger, 1957), rendered dysfunctional by the incongruity of their fate with all they had previously believed about themselves. The reck oning would include costs of medication, therapy, and hospitalisation as a minimum. The societal costs incurred through people being unable to perform their normal family roles is perhaps for back-to-basics politicians to address. In the spirit of evidence-based medicine, this author suggests that it may be worthwhile to investigate further the link between mental illness and marketdriven pressure for organisational change.