by Rachel Gibbons (2025)

Reviewed by Mike Chitty

Rachel Gibbons’ recent contribution to Psychodynamic Practice offers a lucid and unsettling diagnoses of NHS organisational culture. Moving beyond typical accounts of staff burnout, under-resourcing, and institutional inertia, Gibbons draws on psychoanalytic and symbolic frameworks to reveal the deeper currents that trap health professionals in a cycle of sacrifice and despair. Her core thesis is that working in the NHS today is not merely difficult, but psychically impossible, unless one submits to being ritually sacrificed to maintain the illusion of a benevolent, functional system.

The ‘Primitive God’ of Sacrificial Health Work

At the heart of Gibbons’ argument is the symbolic function of sacrifice. She contends that NHS workers, particularly those in caring roles, are not merely overworked, but sacrificed. Their wellbeing, values, and often sanity are consumed in service of an institutional mythology that cannot bear to confront its own incoherence. The “primitive god” in this case is the organisation itself, sustained not by functional governance but by ritual acts of devotion and denial.

Sacrifice is not a metaphor but a defence mechanism. It keeps the wider system stable, even if it means destroying those within it. The sacrificial offering is the emotional and moral integrity of frontline workers, those whose care is most authentic and whose suffering is most repressed.

Psychodynamics: Splitting, Projection, and Denial

Gibbons makes good use of psychoanalytic concepts to explain how this dynamic is sustained:

• Splitting: Staff and systems alternate between being idealised (“heroes”, “angels”) and denigrated (“troublemakers”, “burnouts”), rather than being seen in their full humanity. This fragmentation protects the system from integrating contradictory truths.
• Projective Identification: Organisational anxiety is offloaded onto individuals, who are then punished or marginalised for manifesting it. This is particularly visible in the treatment of whistleblowers and dissenters.
• Denial: Leaders and institutions deny systemic trauma by overemphasising strategy, data, and performance management, mechanisms that conceal emotional and moral breakdowns beneath a veneer of rationality.

The result is an emotionally broken culture that expects moral performance without moral support, a theatre of virtue sustained by suffering.

Implications for Leadership and Organisational Culture

One of Gibbons’ most important contributions is her challenge to prevailing models of NHS leadership. Rather than calling for better metrics or resilience training, she calls for psychic and symbolic honesty. NHS leaders, she argues, must become aware of the unconscious dynamics that animate their institutions: the roles they play in sacrificial rituals, the stories they tell to justify harm, and the fear of confronting institutional grief.

She invites leaders to:

• Develop emotional literacy, able to name and work with shame, guilt, and projection.
• Hold spaces for collective reflection, not as a form of managerialism, but as a way of honouring moral experience.
• Resist the myth of heroic individualism, which feeds the sacrificial logic, and instead embrace relational and collective leadership.

In doing so, she implicitly aligns with broader movements that seek to embed ethics of care and process-relational thinking into public service cultures.

The ‘Impossibility’ Reframed

To call working in the NHS “impossible” is not to suggest it cannot be done, it is to suggest that, under current conditions, it can only be done by engaging in forms of self-abandonment that ultimately dehumanise. Those of us who work with colleagues who have sustained NHS careers will recognise this phenomena. Gibbons reframes this impossibility not as a failure of individuals, but as a systemic indictment. She names the collective delusion: that we can continue to expect quality care, moral integrity, and emotional labour from professionals while denying them the psychic and structural support they need.

Her paper, then, is less a critique and more a call to consciousness, to notice what we have repressed, to question the gods we serve, and to remember that care cannot survive where sacrifice is demanded.

A Leadership Ethic for the Post-Sacrificial NHS

For those working in leadership development, Gibbons’ insights offer an urgent provocation: our leadership paradigms must evolve. The NHS cannot be reformed by better targets, slicker dashboards, or even more compassionate rhetoric if it continues to rely on unconscious rituals of self-sacrifice. Instead, what is needed is:

• A shift toward collective responsibility, where care is not individualised but shared.
• A refusal of martyrdom, cultivating leadership that names its limits and honours its own needs.
• The development of psychodynamic fluency in leadership education, recognising that what is not spoken still shapes what is done.
• The cultivation of process-relational awareness, where institutions are seen not as machines to optimise, but as evolving fields of relationship to be tended.

Such a shift would require leaders not only to learn new skills, but to undergo a kind of moral and emotional reckoning: a willingness to listen to the unspoken, to disrupt sacrificial norms, and to reimagine care as something grounded in shared vulnerability rather than heroic endurance.

Conclusion

Rachel Gibbons has written a rare thing: a paper that is both clinically astute and politically courageous. By drawing attention to the unconscious sacrifices demanded by NHS culture, she gives voice to what so many feel but dare not name. In doing so, she opens the door to a new conversation, one in which care is no longer confused with suffering, and leadership becomes an act of deep, relational responsibility.

Her paper deserves to be widely read, not only by clinicians and psychotherapists, but by health leaders, policymakers, and anyone seeking to restore soul and sanity to public service. For those of us working at the intersection of ethics, process, and leadership, her work is not only insightful, it is indispensable.

If you would like to explore this paper further and its implications for your leaders or leadership please do get in touch.