partnerships within organisations · team dynamics in psychotherapeutic milieux a literature review...
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Partnerships within Organisations
Australasian Therapeutic
Communities Association
Conference
Karen Blacklock
October 2015
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Team Dynamics in Psychotherapeutic Milieux
A literature review
2014
Karen Blacklock MHSc Psychotherapy
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Introduction
Treatment settings• TCs, residential treatment, inpatient
units, forensic settings
Client groups• range of services, personality types,
degree of psychological difficulty• addiction, eating disorder,
adolescent, forensic, services.
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Three strands of literature
• Team countertransference to clients
• Our own stuff
• Organisational/social political influences – the wider context
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Central Concepts
• Transference
• Countertransference
• Splitting
• Projective identification
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Team countertransference to Clients
• Splitting
• Projective identification
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“When one adds to the multitude of emotional reactions to any client the
multitude of staff reactions to other staff members, one has an exceedingly complex
web in which treatment takes place”
Eisenberg (1997)
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Team Countertransference
to Clients
• Tom Main 1950s
• Two examples
o sedation of clients
o‘nursing failures’
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Power of the TC setting
•24 hour care;
•a number of clients living together;
•a high degree of psychopathology;
•new mental structures evolving quickly
• TC therapists often receive less training and less recognition than individual therapists
•clients’ greater dependence on the TC therapist
•action instead of thought
•packed timetable
• ‘last minutisms’ – reactive, crisis led mentality
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Team Countertransference
to Specific Client Groups
• clients with borderline personality organisation
• adolescent Clients
• clients with substance dependencies
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Intense Team Dynamics
• highly charged atmosphere in teams
• defensive behaviours
• services on the brink of destruction
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The Team Unconscious
• clinicians’ personal history
• unconscious motivation for the profession.
• the team members’ and team’s contribution to the relationship dynamics in the TC.
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The Team Unconscious
• disavowal of aggressive impulses and fear of conflict
• collective anxieties and defences
• competition, rivalry and envy
• transferences to colleagues
• problems of multi-disciplinary teams
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The Interrelationship of Clinicians’
and Clients’ Intrapsychic Material
• the dynamic of helplessness
• staff and clients unconsciously conform to the only two roles on offer
• staff unconsciously require clients both to stay unwell and to recover
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The Struggle to Face
Difficulties in the Team
• importance of the team’s ability to think critically about its own functioning
• benefits to staff and clients
• maintaining open communication difficult
• fear of supervision, evasion, resistance, and cover-up is a key problem
• sense of support within the team was named as extremely important
• emotional safety
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Unconscious Processes in
Organisations
• Organisational defences
• Hierarchy, power and status
• Scapegoating
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Socio-political influences on TC• Growth in right wing conservatism, neoliberal
economic paradigm a negative influence on TCs
• Biological fundamentalism displaced psychodynamic training and treatment
• Managed care – restrictions on services
• Increased stress results in inability for organisations to provide containment for teams
• Impacts on teams ability to provide containment for clients.
• Cultural context – a gap in the literature
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Effects of Conflictual
Organisational Dynamics
• defensive Practice
• burnout
• effects on clients
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The inevitability of enactments
Enactments of splitting and projective identification in the therapeutic TC can be seen as “a set of cycles, moving from action, to reflection and understanding, and then back to actions – a form of psychodynamically informed action learning” (p. 12). This repetitive cycle of enactment and making sense may gradually help clients towards integration and the ability for self-reflection.
Griffiths and Hinshelwood (1997).
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Overall Findings:
The team unconscious is multilayered
• Clinicians’ personal history and motivation
• Interaction of clinicians’ and clients’ intrapsychic worlds
• Splitting, projective identification and countertransferential enactments
• Specific client groups
• Structure and culture of the organisation
• Social-cultural context
• Political context
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socio-cultural context
nature of organisation and type of treatment setting
specific client groups
splitting, projective identification, transference
countertransference enactments
make-up of clinical team, and manner of operating
clinicians' personal history and motivation
Political context
socio-cultural context
nature of organisation and type of treatment setting
specific client groups
splitting, projective identification, transference
countertransference enactments
interrelationship of clinicians’ and clients' intrapsychic material
make up of clinical team and manner of
operating
clinicians' personal history
and motivation
Figure 1. Layers of influence upon team dynamics within psychotherapeutic TCx
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Recommendations
• Creating a culture of enquiry –reflective spaces
oThe reflective Space - making sense and avoiding clinical chaos
oThe responsibility of institutions to provide a reflective space
• Personal Therapy
• Training for TC staff
oTraining on TC principles
oTraining on unconscious processes
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Conclusion
• Unconscious dynamics are ubiquitous in TCs• They are complex and multi-layered• Unresolved conflict has a destructive impact
on clients and clinicians• Acting out unconsciously is inevitable;
making sense of this is reparative • Space is required to think about what
happens in our teams• Recommendations
Training on TCs and team dynamics Personal reflection/therapy Reflective space/supervision