Holding Turbulence from within: internal consultancy in an NHS psychiatric intensive care unit

This paper explores what it means to hold organisational turbulence from within. It draws on my experience as an internal organisational development consultant in an NHS mental health trust, focusing on a consultancy intervention with a psychiatric intensive care unit (PICU) for adult men. The wider context is an NHS under severe strain, marked by rising need, low morale and particular pressures in mental health services (Darzi, 2024), as well as what Gibbons (2025) describes as an idealised fantasy that the NHS can provide unlimited care.

The PICU had lived through a period of acute disturbance: serious incidents, patient injury, staff suspensions, high levels of violence and aggression, staffing instability and reputational exposure. Although the formal task was framed as culture and values work, the consultancy became an inquiry into how a ward, its leaders and the wider organisation might recover the capacity to think when fear, shame and the drive for survival had come to dominate everyday work.

The paper uses this case to examine turbulence not only as an external condition affecting organisations, but as something that becomes lodged in roles, routines, spaces, bodies and relationships. In the PICU, turbulence appeared in communication breakdowns, mistrust, informal alliances, confusion about authority, over-reliance on rules, fear of accusation or blame, and a displacement of the primary task from therapeutic care to getting through the shift safely. Interventions to address this included staff coaching, leadership development work and boundary-spanning work to connect senior stakeholders around organisational problems that were being located primarily in the ward.

Drawing on systems psychodynamic and socioanalytic traditions (Bion, 1961, 1962; Menzies Lyth, 1960; Obholzer and Roberts, 2019), I will explore 1) how the ward’s anxieties were not simply ‘in’ individuals but carried by the system as a whole and beyond and 2) how I and a colleague created a series of ‘compelling spaces’ (Horowitz, 2004) where individuals, pairs and groups, with the help of transitional objects such as visualisations and sculpts, could pause, think and speak more honestly about what they were carrying and subsequently improve their capacity to learn, take professional risks, innovate and develop their individual and collective authority.

The paper will also turn the analytic lens back onto my own role. As an internal consultant, I was not outside the turbulence I was trying to help contain. I was employed by the same organisation, dependent on its authorisation, implicated in its politics and pulled e.g. between inquiry and reassurance as well as challenge and repair. The work raised the question: how can an internal consultant maintain enough distance to think, while remaining sufficiently connected to be useful?

I will argue that new forms of holding in organisations experiencing turbulence may depend less on ‘heroic’ containment by leaders or consultants and more on creating modest, repeatable practices through which anxiety can be named, roles clarified, authority can be taken up and the primary task recovered. The paper contributes a first-person, practice-based account of internal consultancy in a mental health setting, where the work of containment must be negotiated from inside the very system that it is struggling to hold.