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11.1 Health Care in oscillation

The Health Care System (HCS) is, as all living systems, constantly adapting to changing demands. Of the numerous subsystems of which an HCS consists each is governed by it's own laws, and is at the same time responding to challenges from outside. By mutually influencing each other the subsystems form together a more or less coherent aggregate. As the lumbering HSC slowly moves forward, feeling it's way, moving around political obstacles, it resembles the slug consisting of amoeba cells that has been J.T.Bonner's object of study. Remember how the chemical call of AMP brought the dispersed cells together to form one body? This has now happened to the practises, hospitals, nursing homes, health-insurances; they are all connected by inescapable rules, regulations and buzzing communication lines.

Forty years ago I set out, determined to understand the how and why of communication disorders. It is now the time to sum up what has changed and what is going on in this section of health care, and in what relation it stands to human communication in general. We see the ceaseless struggle between the Old and the New, a dispute in undulating motion. The New ventures into unknown territory, it reports novel encounters. Subsequently it is called back by the Old which puts forth its traditional wisdom. The oscillatory period ends when together they reconcile their differences and incorporate newly won territory.

I'll be more specific about the disputes that have enlivened the scene of communication disorders and health care in general. The set of subsystems, represented as "old", is a traditional form of medicine. It is visually oriented and focussed on matter and organic pathology. Its way of thinking is causal, "objectivity" is very much in the foreground. A patient's complaint is explained by an organic disorder or it is not explained. In the latter case it is called a functional disorder and the patient is sent away with a pleasant "we haven't found anything wrong". The "old" has a paternalistic attitude and instantly closes it's eyes for anything that is not strictly medical.

Another set of subsystems in the HCS, represented as "new" has developed more recently and is mainly derived from the behavioural and social sciences. It focusses on mind and function, has a listening attitude, takes into account subjective experiences and the perspective of the life history. Its way of thinking is goal-directed, it respects the individuality and the autonomy of the patient. The "new" therapist relates to the patient as an equal and is not afraid to expose his personal limitations and uncertainties. A summary is given in the figure below.

The "old" and the "new" have at times had a difficult relationship, alternately abusing and ignoring each other. However, when they have communicated and in turn have listened and spoken to each other, this has led to considerable improvements. We have seen for instance that child abuse and incest were rarely noticed by the "old" until close observation and unprejudiced attention to life histories revealed that such trauma's in childhood and their harmful effects on development into adulthood are not at all rare. Since "new" and "old" have worked together, attending to these family tragedies has now begun to become a part of health care. Every year thousands young victims of family violence are seen. The next stage in this development will hopefully be that by proper education and counselling a potential perpetrator will be prevented from committing brutal acts.

I mention the instance of child abuse because among the victims are people who, at an early or a late stage in their lives develop a disorder of voice, speech or language. The remote cause of the dysfunction has often gone unnoticed, especially when the medical consultant or the clinician in charge has been attracted by the interesting acoustic, speech-motor or linguistic aspects of the disorder and was blinded by those to its remote origins and to the factors that maintain it. For the patient of course a blind alley without prospect of a cure. This brings me to another potentially growth-stimulating dispute, that will also go on forever.

The rift between research and clinical work is a controversy that is even harder to reconcile than that between the Old and the New. To those, attracted to the crystal clear world of science on the sixth floor, the drudgery of clinical practice in the basement is so remote that they will never set foot in it, unless they are in need of subjects for tests and measurement. Even then they prefer to deal with it by telephone. Clearly the dialogue is a struggle, a battle of unequal opponents, unequal kinds of intelligence, unequal temperaments. The outcome however may be good if, despite of frequent clashes, neither party has the intention of damaging the other. If, after every clash at least one of the parties has learned something, the dialogue has been successful. Conjunction of parties in oscillating struggle will increase knowledge and improve the quality of therapy. In the case the upstairs scientists in dispute with the downstairs clinicians, as well as when the "old" encounter the "new".

The word "therapy" is derived from a stem meaning help, support or heal. Therapy in the "old" sense includes the application of drugs, diet, surgery and counsel. By the renewal discussed above, therapy now also includes deliverance from emotional and mental damage, and reeducation with emphasis on the deep layers of the personality (psychotherapy). Human motivation is governed by expectations based on past experience. An idea or construct that has been an adaptive response when the person was coping with his environment as a child, will later mould an adult's outlook on life and influence his habitual life style. By then, the idea may have become obsolete and be maladjusted in the then prevailing circumstances. Under skilful therapeutic guidance a person can prepare himself to replace old prejudices by new interpretations of meaningful elements in his environment.

Principles of behavioural analysis and treatment should be taught in the medical curriculum because they are not yet incorporated in daily medical practice. Such training is indispensable in order to prevent medicine becoming an island of stagnant conservatism in a dynamic society. Medical schools where these subjects are being taught sometimes experience them as foreign bodies in an otherwise homogeneous curriculum of biomedical topics. The gap between a biomedical and a social-psychologic approach is not yet closed. As long as the two different scientific cultures are not on one continuum, they will remain strangers to each other. The clues given in this book to clear up the body and mind relationship should be of help to bridge the scientific rift. A health culture which includes both, will probably not come in one bright flash, but by gradual illumination of both the physical and the mental aspects.

Medical culture Behavioural culture
focus: on organic structure on activity and function
objective perception subjective experience
synchronic section perspective of life history
causal orientation goal-directed orientation
curing positive health, prevention, healing
caregiver is responsible responsibility is with both the caregiver and the patiënt
paternalism autonomy

Map 11.1 Area's open for reconciliation in medical and behavioural cultures

A short note explaining why the word re-education is appropriate for the kinds of therapy discussed here. The prefix re- does not mean a repetitive action or a return to a preexisting condition; it indicates a purposeful direction. Like the Greek ana-, it can mean: (carrying something) up to the desired place. That is: goal-directed education. In some cultures reeducation is a form of remedy for persons with a criminal past. Such connotation is of course not applicable here. We think of people who have been emotionally bruised in the past, very few of whom resort to criminal behaviour.

A complete program of therapy and reeducation involves any or all of the spheres of the personality. When a surface structure is being worked on and the therapist meets stagnation or resistance, this is a reason to proceed to a more central level or sphere. In the review that follows we shall discuss each personality sphere as it appears in its mature form, we'll also note certain weaknesses and their consequences. Because therapy is an interactive process, weakness in the therapist or counsellor is as important as it is in the patient. Fortunately it is possible that during the interactive process the therapist conquers his weaknesses and misconceptions at the same time as the patient. The condition for this to happen is that the therapist is authentic in his responding to the patient and ready for change.

11.2 The personality spheres.

11.2.1 Identity

Identity is experienced as being aware that one exists and that one has the right to live. The person accepts his limits and is prepared to exert his right to exist. He derives strength and courage from a basic feeling of security, from self-confidence and faith in others. He accepts responsibility for his behaviour. A patient with weakness in the sphere of identity feels insecure, "not O.K."and avoids responsibilities. This often obstructs progress in therapy. Strengthening identity then has a high priority.

A therapist may lack strength and credibility because of a weak or faked identity. If this is the case one can hardly expect a patient to experience basic security in his/her presence.

11.2.2 Intimacy

Humans are social animals. One of the first needs of an individual is to relate closely to one person in particular. This produces bonding between infant and mother. Later in life the intimacy of lovers and close friends develops, one learns to be close to others without losing one's own identity. Intimacy develops on the edge of fusion (identification with the other) and self-assertion. The antithesis: fusion versus autonomy is solved by "sharing". A person who feels supported by a strong feeling of identity can reach out and become intimate with others thereby enriching their lives. The intimacy offered in return, is a reinforcement of one's own identity. If something in the sphere of intimacy is lacking, a patient may experience trouble in developing adequate social coping skills. In a therapist an unrequited need for intimacy may give rise to problems: the transfer of feelings by the patient to the therapist may cause confusion and elicit inadequate responses.

11.2.3 Drives and emotions

The art of living is making the right choices and decisions. This aspect of human behaviour is studied by motivation theory. It is an important domain for the communication pathologist: many disorders have their beginning in this sphere.

The patient who has lost control over his voice or speech often has to reexamine his priorities in life. Is he satisfied with his work, what can he do to feel better about his family relations, who are his friends, can he depend on them, can he make his choices from a position of self-respect? Before the outbreak of a psychogenic loss of voice there has often been a period of inner confusion. Under the appearance of a perfectly regular and well-organised life, there has been inner dispute, irresolution, or even despondency, there may have been existential crises. In this situation the patient needs a reliable guide to counsel and support him until he is sufficiently "reorganised" to withstand the adversities of life by drawing on his own resources. The "Old" practice of dealing with "these hysterics" by surprise tactics or suggestive exploits is callow or at best naive.

Choosing the right counsellor can be difficult for the patient, especially when he is in emotional disarray. More than one patient with a beginning spastic dysphonia, who could have been healed by adequate psychotherapy and reeducation, has accepted medical help that has piloted him into the quiet harbour of permanent disability (surgery, beds and benefits included). It is a weakness in the health care system that patients are seldom fully informed about cognitive and behavioural therapy. If they are, it is a choice between unequal alternatives. The reeducation therapist is at a disadvantage because he/she can only offer hard work with uncertain outcome instead of surrender to partial disability, with the accompanying tokens of sympathy.

11.2.4 Relating socially

In the process of self-actualisation this is the buffer-zone that people build around their identity and intimacy. Human drives and motivations are consummated in the social sphere: identity is fostered, intimacy has to be actualised in a social context. Interaction takes place with members of the family and other people in the environment, in an ever widening circle. Out of early experiences with socialisation a complex scene of transactions between people will grow, which E.Berne has aptly described as activities, pass-times and "games". A fair number of games get people entangled in risky social habits of which they themselves are hardly aware. A life-scenario with unwholesome games may include some vicious speech- and voice neuroses. Replacing the dominating games and changing the scenario, by role-playing and practising game-free relationships can bring about a profound change. It will bring the person closer to a true feeling of identity (instead of a fake one) and to genuine intimate relationships.

11.2.5 Creative energy and the power of will

Men and women are often judged by the impression of power they display in carrying out their designs and resolutions, in demanding achievements from themselves and in dominating others or, on the other hand by submitting to others. Phantasy and creative power are important factors in people's lives, and so are ambition and perseverance to carry out one's design.

The fulfilment of most aspirations and expectations needs time. Impatience and haste are widespread disabilities in people who feel insecure. Physical features belonging to this state of mind are hurried superficial breathing, an incontinent rate of speech. Working on these features may be a good point of entry for body-oriented therapy.

On the level of thinking, reasoning, evaluative judgments, people must also learn to take the time it needs. They will do so if they think of themselves as competent and worth while.

11.2.6 Cognition: perception, discrimination, evaluation

In this sphere the person keeps his internal image of the environment and of his own functioning in this environment. Cognition has been collected from and pervades all previous levels: identity, intimacy, emotional self-preservation, relating to others, creativity and willpower, have their involuntary controls as well as a conscious representation. By rational thought the person tries to make sense of what is happening to him and to his environment. Rational though they may seem to be, thoughts may be subject to distortion: Misinterpretations and false expectations may occur as a consequence of exceptionally strong experiences dating far back in time.

The therapist's cognitive skills are his most obvious instrument . Such skills are however powerless if not activated and supported by creative energy (level 5) and guided by social intuitions (level 4). They may become blocked or misdirected if the more central levels, the emotional life, intimacy, identity are inadequately developed. If well developed they enable the therapist to intervene at the right time, by the right gesture. The equilibrium in an individual is never static. Its being dynamic is the reason why well-timed therapy helps an unpoised person to regain his balance.

11.3 Spheres in the process of voice- and speech production.

Respiratory control is a condition necessary for meaningful use of the voice: calling, singing, speaking, whispering. In a treatise on men's (and women's) evolutionary past, E.Morgan (1972) states that vocal communication is especially suitable for mammals living in the sea such as whales and dolphins. Respiratory control is a prime necessity for under water swimming. It's use as a secondary function for vocal communication could well have developed in an episode that man's ancestors were living in the shallow waters off the East coast of Africa (the aquatic ape theory of the evolution of man). Controlled breathing and voice-production together with consonantal articulation, make for understandable speech. Posture and respiratory control require the coordination of large parts of the body: the legs, the basin, the vertebral column, the shoulders and the neck. Body posture and movement is partly under involuntary control and has an important share in non-verbal communication. Significant postural oppositions are
laxness - firmness
diminution (submission) - enlargement (dominance)
closeness - distance.

Each of the postural variations goes along with a different way of using the voice. That is one of the reasons why remedial training of the voice requires thorough physical groundwork. The quality of the voice derives from the layers that together form concentric man: a visceral layer, a muscular layer and an integrative neural system. The idea of concentricity is also reflected in the model which we use for imaging the expressive use of movements, gestures and voice. Large expressive movements are controlled from the centre: the legs and the trunk perform approaching, threatening, or shrinking movements. Gestures for the middle distance are controlled by the arms, head and neck. Finely tuned expressions of the face are produced right on the surface of the skin. A comparison with the proper technique of playing the violin will be helpful. A steady stance with the legs well grounded supplies a firm support to the trunk and the shoulders. From there the arm is moved, transmitting its movement to the wrist and from there to the fingers. When based on "grounded" stance of the trunk the control of the bow by the fingers is more secure than if the control were not "centered". In a similar way successful and convincing speech begins with standing with both feet firmly planted on the ground. Controlled respiration supports a resonant voice, gestures of arms and hands add to the elocutionary liveliness, oral and facial movements bring about the articulatory clarity. 

How do we practice all this? When Germany still had colonies in Southern Africa, it founded a department of phonetic sciences in Hamburg to study African languages, under the direction of a medical doctor G.Panconcelli Calzia. A vestige of the African connection is still present in the "Accent Method" applied by a later director of that department, the Danish professor Svend Smith Ph.D. According to him, a weakness of the internal temporal organisation of speech underlies many voice- speech and language problems. He uses African drums to accompany his clients when they become aware of the main rhythms that envelop each other during verbal expression:  
LARGO is the slow beat which is at the foundation of self-confidence. Awareness: my voice is there when I need it, I won't let myself be hurried 
ANDANTE is the easy-going movement when short phrases are exchanged,taking turns in alternation  
ALLEGRO represents the rapid flow of syllables in fluent speech. 
Since we introduced the Accent Method in the Netherlands in the sixties, it has been widely used by logopedists.

11.4 Stages in the rehabilitation of voice- and speech disorders

Most voice and speech disorders have a non-organic origin, they are caused by inappropriate usage. In other words, if you look for a damaged or defective part of the speech organs you may find one, but it is more likely the consequence than the cause of a dysfunction. A vocal nodule may be the "causa proxima" that prevents a teacher to speak with a clear voice, but the remote cause is the dyskinetic use of her voice. This has put an extra load on the vocal folds and the tissues show the consequences. The question is: can she acquire a new and better habit of using her voice, can she learn to cope with difficult days in the classroom, and become less tense under adverse circumstances? Similar questions can be asked in the case of a stutterer who would like to free himself from his speech habits and automatisms.

One of the great founders of communication pathology was Charles Van Riper (Kalamazoo, Michigan). We have already met him in Chapt. 10. He was an educational writer of great merit and originality. In his works on the treatment of voice- and speech disorders he introduced a systematic order of treatment, summed up in MIDVAS, a mnemonic device consisting of the first letters of the following sequence.

Motivation is the decisive factor in the treatment process. Many a patient who consults a clinician or a doctor hopes that he will be relieved of his problem in a simple way, a shot of an antibiotic, perhaps a little less smoking, or, if it must be, a minor operation. When the clinician proposes an intensive course of reeducation, implying that he will have to practice daily and will have to change some precious old habits, this may be more than he is willing to do. Much depends on the competence of the therapist to motivate the patient to venture into unknown territory. When the patient gives the therapist his trust he expects to get this credit repaid in results. After the first obstacles have been overcome motivation is fed by the drive to attain lasting results and an attitude of positive expectation that in turn is fostered by initial successes. Motivation-credit does not last indefinitely, results will have to show up soon to keep motivation going. A clear outline of the therapy in steps that are within reach of the patient will help to keep the spirits up.

By Identification the patient discovers that the dysfunction is part of himself and that the only way to improve the situation is by coming to terms with the treatment plan and by assuming co-responsibility for it. This is a large step. Patients with a voice or speech complaint have a tendency to ascribe the problem to external causes: predisposition, a virus, or just nerves. In the first treatment sessions the patient should explore the ways he uses his voice, the rate of his verbal output and other relevant details. This is to overcome the feeling of helplessness, of being powerless and at the mercy of his dysfunction.

During the Desensitisation phase the client frees himself of the fears and avoidance tendencies that inhibit him to touch the painful subjects that relate to his dysfunction. He loses his shyness and finds the courage to face the issues to be worked on during therapy. It is important in some stutterers whose symptoms are induced by negative feelings, such as an aversion to a situation in which speech inhibition tends to occur. Also patients having a voice disorder may have strong emotions: anger about being incapacitated, worries about the future, annoyance about being unable to change the situation. A strong emotion may in itself cause voice dysfunction. Anger or anxiety, causing agonistic moments, impinge upon the smooth automatism of speech, resulting in ugly interruptions, moments of roughness and other dyskinetic symptoms. When repressed feelings are not allowed to come to the surface, the tenseness to keep them down will stay as long as the patient has no other way of coping with his anger, dislike or hatred. Note the paradox: stuttering and dysphonia may be part of the defence system and anything, treatment included, that is aimed at breaking down the defences will invite resistance.

Variation is the procedure to let the client experiment freely with changes in his usual behaviour that has caused the problem, try out alternative ways to interpret his environment, if some misconception was at the base of his communication disorder; in short to break out of his former confines. This stage passes into the next:

Approximation: focussing on desirable behaviours and attitudes by response substitution, sensomotor practice, role playing to learn to give adequate expression to feelings of approval, anger or disapproval. All new possibilities need to be practised. By trial and error the patient will learn to come closer to the goals he has set in his life and had not been able to realise.

Stabilisation is the final phase in which the newly acquired behaviours and attitudes are introduced in situations of daily life and practised until they are strong enough to take the place of the former habitual behaviour. As long as the new voice or speech behaviour feels "strange" it can be easily lost. The old habit will take it's habitual old place. This is likely to happen if the new behaviour has been imposed on from outside, not grown from within. When the identification phase of treatment has been successful, the patient has taken on his own treatment and can work on his problem independent of the therapist.

The MIDVAS sequence is not as simple as would appear at the first glance. Each of the phases in the process of change can become an obstacle, leading to stagnation. In order to proceed, any single phase may in itself need a complete work-over with the MIDVAS cycle. When during the stabilisation phase the new behaviour (voice or speech habit) is not carried over into daily life, it is likely that the process of identification has not been successfully completed. This , in turn, can only be attained after the client has acquired sufficient self-confidence (basic trust) so that he can maintain a radical change in attitude and let go those he used to depend on. Thus MIDVAS is a recursive procedure and as such a veritable enzyme for growth.

11.5 Requirements for the therapist

Patients having a functional voice or speech disorder have very special needs, not in the sense of sophisticated equipment for assessment of the physiology and acoustics of speech and voice, but in the sense of a trustworthy and empathic therapist. Renowned institutions have been shown to fail in this respect, when their culture was more scholastic than humanistic. The therapist should be a role model for those functions he expects to develop in his patient. If he is suffering from "thymophobia", the fear of emotional issues, this will result in over-accentuation of organic pathology at the cost of the functional aspect, which is the relevant part in reeducation. We recapitulate the concentrical spheres of the communicating individual, this time with the ideal therapist in mind:

  1. Basic trust in himself and in even the most difficult client
  2. The capacity to experience intimacy
  3. True motivation, emotionally dynamic personality
  4. Genuine affect and social skills
  5. Imagination, resolution, power, persistence
  6. A broad understanding and clear insight in life-histories and life scripts

We have seen interesting recent developments in the area of attitude- and personality training. There has been a sudden and unexpected recognition of a large family of therapy procedures which had been leading an underground existence. Active relaxation, body-awareness, controlled breathing, stretching and other forms of body-oriented work had been common practice in many private institutions in Europe. They were, with very few exceptions not taught at universities: these practices belonged more to the crafts than to the arts and sciences. The occasional young scientist who discovered the value in these "crafts" and brought this to the attention of his colleagues put his reputation at stake. It is appropriate in this connection to mention B.Stokvis at the medical department of the university of Leiden, who was one of the early psychiatrists practising body-oriented therapy. When the sixth floor scientists began to open half an eye to explore the "new" possibilities, they were surprised to find that the clinicians in the basement already had a long body-oriented therapy tradition. It was the start of a productive cooperation between upstairs and downstairs. There have perhaps been disputes over questions of competence and qualification. However in the light of present day attempts at accurate task descriptions and professional quality improvement, conflicts can be solved.

Many people are in need of reeducation of voice or speech impediments or want to improve communication skills. When they can receive the required training from a professional in voice- and speech therapy they will opt for this sooner than if they would have to apply for psychotherapy. In the first place the threshold for entering therapy is lower and secondly the objectives of the therapy program remain in sight.

11.6 Processes of change in other contexts

In the previous chapters many concentric structures in nature and man have passed in review. In this final chapter I have discussed examples pertaining to the delivery of health care, especially in cases of communication disorders, because they are in my area of expertise. Whenever I catch a glimpse of developments in other area's I see that a similar systems approach is being applied. 
When R.Zuyderhoudt discusses processes of change in organisations, he mentions regression as the starting point for the development of a new order. Rigid defence of the old self-image is bound to succumb to the winning appeal of new experiments, one of which will be incorporated in the new and more complex order, having gone through a process of variation and selection. All living systems are bound to operate in the small margin between stability and chaos. They have been selected as such, because over-stability as well as chaos lead to a certain death.

Ian Metcalfe, an Australian  organisational consultant, in a correspondence with me has contributed his views on organisations.  
"There is no doubt in my mind that organisations when viewed as 'living, growing, organic' entities (rather than as mechanisms/machines as has been the prevailing view throughout the 18th & 19th centuries) exhibit the concentric pattern you describe. After all, organisations are just one natural way for people to gather (organise) to get things done (just like teams & societies). Humans and organisations are members of a special class of complex adaptive systems - that is they are made up of other components which are in themselves complex adaptive systems (in the case of us - cells, and of organisations, people). Gell-Mann has a special name for these, IGUS (information gathering & using systems) - they are self-aware, conscious and can manipulate the environment rather than just respond to it. 
I have to mention a book by Collins & Porras called "built to last" because while they do not look at it this way, they propose a concentric model for organisations derived from a study of hundreds of companies which have been in existence for over 50 years.

They were specifically trying to work out why some companies were successful over decades (if not centuries) and others not so successful. The found that the companies which they called "visionary" were many more times successful (over time) than others based on a number of measures (including stock market price & profitability). These were the companies who maintained a "core" along with a very mobile & flexible outer layer which could interact (and change) with the environment. In the (genetic) core was the ideology of the company - why it existed, what did it aspire to, how would it conduct itself (a representative slice of the company's genetic code laid down by the founders) - a source of guidance & inspiration.

Ralph Larson, CEO of Johnson & Johnson once said "We would hold onto the core values even if they no longer provide competitive advantage - even a disadvantage in some situations." The core is irrevocably tied into the identity of the company - lose this and you are no longer Johnson & Johnson… (this has interesting consequences when you look at mergers & acquisitions through this perspective - see later). 

About this and directly influenced by the core is the culture of the company 'how things work around here', 'what are the norms' etc. The duty of the culture is to protect the core and what it stands for. Further out are layers which hold shorter term more flexible elements such as strategic & tactical goals, the envisioned future - how to go forward in the foreseeable environment/markets. Descriptions of "what business we are in", "what business structure should we have", "how do we do work", "how will we look to our customers day-to-day", even "who are our customers" are on the outer layer - very flexible, very responsive to changes in the market place. 

Visionary companies (Ford, Nordstrom, Citicorp, IBM, 3M, GE, Boeing, Amex, HP etc) do everything they can to "preserve the core" and "stimulate progress by changing the 'face' of the company in line with environmental pressures. Do this successfully and the company 'learns'. Organisational memory to store these lessons can be found in people's heads (short term memory), stories, myths, rituals, systems, documents, processes, policies, structures - all what Edgar Schein ("Organisational Culture & Leadership", Josey-Bass, 2nd Ed, 1997), calls Cultural Artifacts.

 Organizational Coping Mechanisms

 Organisations learn very early on that if they are doing well, you just need to keep on doing those things to be 'successful' - that is to survive and to make a profit. This is a more-of-the-same (MOS) mentality or survival method (coping mechanism). The problem is that if the market place/customers/world changes this is no longer an appropriate strategy. Because organisations are made up of people, and people can be blinded by success - some companies fail to evolve (learn) when the environment starts to change. They don't grow with the times or build new layers to defend or grow. These companies invariably go through crisis and die, or change rapidly (downsize, merge) and survive but at huge cost to their employees, customers and identity.

 The Total Quality Management (Quality movement/reengineering) trend of the 1970's was an attempt at a different strategy where companies vied to be better - against some quality standard or benchmark. This is a "better" strategy where a company maintains some level of competition by being faster, stronger or quicker than it's opponents.

 In the late 80's / 90's the "Learning Organisation" came into vogue - the idea being to be "smarter" than everyone else - to have innovation & creativity, to respond to the external environment, to keep the outer layer visible, conscious, scanning, capable by matching external change with the same rate of internal change. On the whole the internal environment (one of trust, compassion, low fear, low anxiety etc) required to support learning organisations just couldn't be tacked onto bureaucratic, hierarchical, old-fashioned cultures. For this change to be made, deep surgery (deep realignment of previous layers - down to a change of culture) is required. (That is where organisational change consultants try to help). The same 'culture' you describe for the optimal raising of self-aware, happy, well-adjusted children are precisely the same internal environment required for learning organisations to exist and for exactly the same reasons.

 In the new millenium a new strategy has evolved - "different". This is where organisations stop trying to compete with the market place as a level playing field, but attempt to change themselves and the environment so that they look completely different to the customer! Take the coffee shop chain "starbucks" for example - they don't sell coffee, they sell "an experience".

 Compliance & Innovation:

A pair of growth/balance systems found in organisations are compliance/innovation. To adapt to environment (market) companies must be creative, change, innovate products & services etc. On the other hand internal and external compliance is seen as important to "defend against" governmental rules, other companies and the unruly element within which might get out of hand. (There are many cases of individuals 'going rogue' and bringing down a company. Ie: Barings Bank a few years ago.) I wonder if it is the oscillating interplay of these forces/systems which gives rise to a similar concentric 'structure' in businesses as you have found in other complex adaptive systems (ie: man).

As per your analogue of a castle/town being built up to a walled village - with depressions still visible of the moat, motte & bailey etc… we too see "artifacts" that mar the rings of organisations. Often compliance-generated-rules (policies, processes, procedures) outlive their intended purpose and can be found living on well after they should. The environment has moved on, the needs changed, but such artifacts remain embedded in organisational memory - the culture, documents, work-practices and structures. 

Sometimes the natural re-alignment of a new concentric shell with previous shells doesn't work and we get a very uncomfortable/unhealthy 'bulge' in the system. Really good companies are looking inward AND outwards - scanning for internal inconsistencies and removing them while being on the look-out for new changes in the market-place.

Merger & Acquisition:  

 In the world of business we have acquisitions and mergers (which certainly have implications on the identity of the new entity) and well as symbiotic relationships (strategic partnerships). Mergers must be akin to the process of procreation - the intake of foreign material in order to create new life (a substantially different company with new capabilities). Unfortunately the company's auto-immune responses can be triggered and quite often the culture of one of the businesses is destroyed - invalidating the reason for the merger in the first place.

Mergers and acquisitions of companies should be very different things, but often the same processes are used and the outcomes identical. One company ‘adsorbs’ the other and gets bigger very quickly. I struggle to find ‘natural’ analogues but the following come to mind.

·       Acquisition - Company A eats company B and breaks down B for food/energy using little of B’s form. B dies. A thrives but must incorporate the new 'B' material core-to-surface & surface-to-core to ensure alignment, removal of artifacts, etc.

·       Merger – viewed as natural reproduction. Two companies (male, female) come together and give birth to a third (and then like butterflies, the parents die). The newly formed company has a ‘gene’ mix. In a healthy merger, the new company should have its own identity and start developing from the ‘core’ outwards, building up new protections and adaptations. If it is really lucky, the parents (and we speak of parent companies) stay around long enough to provide a nurturing environment.

·       Strategic partnerships on the other hand, are symbiotic relationships.

Healthy merger or acquisition rarely happens. Because mergers/acquisitions are ‘man-directed’ we play God with the genetic structure or one parent stays (the board or executive) while the ‘losing-side’ moves on too soon. With mergers we try to get instant-maturity and competitive advantage from day one. “Integration” is the word used for the process of bringing two companies together, but it is only skin-deep. The focus is only the outer layers and not what the ‘new’ core should look like. What is “merged” are the plastic/flexible bits on the outside (because these are the easiest to change and the more visible) – the company structure (hierarchy), products, employees. Instead of a healthy new beginning, we are faced with two concentric entities sharing a single ‘skin’ but with two ‘cores’ – Siamese twins.  


Healthy merger: growth from new center out         in same skin (and back in again). New layers forming.  


Competing cores (separate identities) with internal conflicts

         Over time one ‘core’ will shrink (ex-employees leave, processes destroyed, memory erased) and we are left with what appears to be a single company, but with a lot of scar tissue. I suppose how ‘healthy’ a merged entity turns out is a function of how conscious the “creators” are of the natural processes at work, how much they simply let these take place without ‘meddling’ and how close the core values/ideologies of the companies are in the first place."

        As complexity increases, patterns of form make room for dynamic temporal patterns (J.Pringle 1965). 
            Future research will profit by taking this into account.

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