A contribution to the clinical study of healthcare institutions. The ``malicious institution'' fantasy

In France, the lens with which clinical psychology gazes through institutional matters seems limited to what happens between patients and professionals. It pays little interest to the interactions between the administration of the institution, i.e. organizational matters, and the daily clinical setting of mental health care. Unconscious institutional dynamics seem to receive much more attention from management sciences, which sometimes use psychoanalytical concepts to shed light on managerial and organizational problems. This article, based on an action-research study in a French university hospital, aims to shed light on one of the unconscious mental constructs which could be at the root of what several authors in psychiatry have identified as ``institutional paranoia'': the fantasy of a malicious institution. We hypothesize that this fantasy, which attributes harmful intentions towards its agents to the institution, is a recurrent avatar of the typical problem institutional psychology deals with. It is therefore even more specific to hospitals, due to the abundantly documented tensions which they have been faced during the last two decades. We were initially appointed to conduct a ``cooperative action research'' project in a French University Hospital Centre between October 2018 and September 2019, in order to write a preliminary research report on the quality of working life as experienced by its personnel. Four ethnographic qualitative research techniques were used to assess the needs of healthcare professionals: individual and group interviews with teams from all departments (health care, administrative, logistical and technical), on formal or informal times, participant observations in services which were later recorded in a written logbook, interprofessional working groups called ``thematic commissions'' that met for five sessions of 3 hours each and the creation of a digital ``suggestion box'' accessible on the hospital's intranet. Our results show the fantasy of the malicious institution deserves to be isolated due to its three constitutive elements: 1) a blurry institutional governance and incarnation of the hospital's leadership; 2) the recognition of the symbolic power of the institution, including its coercive power; and 3) the attribution of negative intentions to the institution by aggressive projections, which in turn transform it into a persecuting object. We discuss the link between the feeling of belonging to the institution and the feeling of abandonment as experienced by staff in regards to the religious past of French hospitals, and indicate the necessity but also the caution with which research can and must investigate the weight of the personal history and vulnerability of each individual in his or her sensitivity to the representation of the malicious institution. (C) 2020 Elsevier Masson SAS. All rights reserved.