Bridging the clinical-executive gap: Waking up to the inconvenient truths

In 1915, Sigmund Freud focused on the relationship between the conscious and the unconscious mind. He reflected that the mind is like an iceberg: One third is above the water, your conscious mind, and a good two-thirds is below the water, your unconscious mind. According to Freud, the most important part of the mind is the part you cannot see, the unconscious, and which is driving our behavior and choices.

In behavioral health facilities, the focus is on the clients doing the therapeutic work to make the unconscious conscious or to change their behaviors. We hire skilled therapists and techs, create complex integrated clinical systems and environments ripe for change to occur. We are mission driven and passionate about the best patient care possible. Is the best patient care possible if we are not doing our own therapeutic work? If we are not making our unconscious conscious?

In practical terms what happens when we do not actively do our work as leaders and treatment professionals? Some real-life examples of how this can show up in the day-to-day:

• Tension grows between the chief financial officer and the chief human resources officer in your organization. It has been affecting your team and the bottom line for some time, and you have just woken up to the situation.
• A five-year employee has long been a poor performer, is absolutely adored by the team, and no one has ever intervened.
• We have gained 10 pounds and have absolutely no idea of how it happened.
• We work long hours, travel for work more days than not, and fail to see the signs of struggle in our own marriage and/or children as we actively focus on other aspects of our lives.

Does any of this sound familiar? These are the inconvenient truths that bubble below the surface of our awareness only to grow larger over time until we become so off-balance and uncomfortable that we must take notice. Some call these “elephants in the room” referring to the large beasts that meander about in our spaces unacknowledged. To our credit, these inconvenient truths do start out small, growing slowly, at first impacting our day-to-day in subtle ways and then growing larger over time. They are often seemingly innocuous, quiet creatures that are so familiar that we simply don’t even notice how hard we are working to maneuver around them.

I call these inconvenient truths for two reasons. First, they are not convenient. If we are conflict avoidant and/or change avoidant, we have likely had childhood experiences that have hardwired us to want to avoid intervention. It doesn’t feel good to us to have to take these head-on, so we unconsciously ignore them.

Second, everyone else can see them but us. Our teams see what is happening, our families feel what is happening, and we are moving lithely along wanting to believe all is well. To wake up to them means feeling vulnerable, exposed and a bit like the fool (one of my least favorite feelings).  

Before we can have an honest conversation with ourselves or others, we must be able to see the truth of the elephant, which begs the question: How do we make the unconscious conscious? It’s no small question with no easy answer. Freud spent his entire career focused on this question and Carl Jung wrote 20 volumes in his collected works, largely on this topic. Buddhists, psychologists, poets and philosophers have all sought an answer. In truth, I believe that the answer comes once we have asked the question, i.e., it starts with our desire to wake up. When we open ourselves to seeing and experiencing the world differently, our unconscious takes this invitation to offer new insights and awareness. Oftentimes the childhood scripts etched in our unconscious, our underlying fears and motivations, and our resulting behavior patterns are laid bare before our eyes. By recognizing how these unconscious patterns have been driving our behavior, we can now begin, step-by-step, to deliberately choose our path forward.

In this waking up process, we may also begin to realize how much of the time we have been operating out of habit rather than mindful and deliberate choice/action. I think of habits like acting on autopilot, i.e., acting from an unconscious place, doing what I have always done without questioning whether this is what I want to be doing or whether it is consistent with who I want to be. When I am acting on autopilot I may be:

• Looking at my cellphone 100 times a night
• Feeling anxious without identifying the source and being reactive throughout my day
• Mindlessly eating when I am not hungry
• Repeatedly nagging my child rather than sitting down to deeply listen to what his struggle is with getting his homework done

Inviting the inconvenient truths to come forward means being willing to change. It means putting the cellphone in a basket by the front door, perhaps talking with a trusted friend, meditating or sitting quietly to identify the source of the stress or anxiety, and deeply listening to ourselves and others. It also means noticing and intervening with the tension between those leaders at work, having the hard conversations with the poor performers, and being willing to be uncomfortable sometimes for the sake of the health of the organization.

Earlier in my career I was blessed to work with an organization that regularly called out its elephants. Every quarter, the leadership came together to openly invite the recognition and discussion of the inconvenient truths that no one really wanted to talk about. These were courageous and sometimes very personal conversations. They called forward emotions, defenses, dropping of defenses and change. They were dialogues that sometimes fought for the health of the organization and engaged us at the deepest levels to be better. I believe that this team stayed together for many years and performed at an extraordinary level largely because of this practice.

What are you doing personally and as an organization to wake up? And what are your practices to stay awake?

Krista Gilbert, PhD, LMFT, is chief executive officer of Constellation Behavioral Health.