THERAPEUTIC USE OF SOCIAL SUBSYSTEMS IN HOSPITAL SETTING A. Cesar Garza-Guerrero, M.D. Reprinted from: JOURNAL. The National Association of Private Psychiatric Hospitals. 7(1):23-30, Summer 1975,THERAPUTIC USE OF SOCIAL SUBSYSTEMS IN A HOSPITAL SETTING A. Cesar Garza-Guerrero, M.D. } INTRODUCTION The treatment program and overall organization Uescribed here is derived from an attempt to integrate psychoanalytic objectelations theory, psycho: analy tie understanding of small and large groups, and “community” methods, considering the hospital as an ‘open social system.' The program was designed for a rather heterogeneous population of patients from the relatively higher level of character pathology ot “well-put-together neurotic” to the severely disturbed horderine or schizophrenic patient. Thus. flexibility, jopen-mindedness, and individualization of ther peutic aims are mandatory. The hospital in which 1 was working utilized psychopharmacological drugs ‘and related somatic treatments, such as clectro: convulsive therapy when indicated. Occupational, recreational, and industrial therapies were significant adjunctive modalities in the program: TASK AND ORGANIZATION TO IMPLEMENT OUR PROGRAM (Our primary task is the psychiatric evaluation and eatment of patients in the broadest sense (¢., the patient is seen as a psychosocial and biological unit). In order for us to implement and carry on this task, we function as a large social system subdivided into wo subsystems, staff and patients, We have a 40 bed capucny. The large social system has been divided into four small "group-hving” 9¢ “prablem-oriented” etups. Each group has a staff member who functions as a leader of the “small group.” These groups are designated 10 examine and maximize the constructive use of intecpersonal relations as they are reflective af intrapsychic conflicts; to analyze and resolve conflicts between individual patients, groups of patients, or patients and staff. These are not psychotherapy groups inthe “analytic sense” for transference implications are not explored in terms of their genetic roots. In these groups, special attention is given to provide these two basic elements necessary for a At the time of siting thie paper, Dr A. Cesar Gar ra Guerrero was in chatge of a prychistic ward at the VA Slospitil im Topeka, Kansas His vices outhned ww this paper hught mo mevesunih reflect those of the Veterans Ad: nitration, therelone the author assumes the entire respomeility for them ir GateaGuersere a6 now a salf pavchiatist at the C.F Menninger Memorial Hospital in Topeka, Kansss, functional working group: clearly defined task and clearly defined leadership. If these elements are not carefully provided, the tendency is toward reac: tivation of primitive object relations and, therefore, regression in both patients and staff. The leaders of small groups carry on the boundary functions be- tween the two subsystems (staff and patients), bringing in basic information to the staff meetings, which in turn is integrated, assimilated, and coordi nated into specific sets of individualized treatment plans for individual patients “Sick people collectively produce health ideas about having a say about their lives. —Hans Falck The patients’ subsystem is organized into a “gov- ernment,” with hierarchial distribution of “power” in 4 way similar to that of the staff social system. There is a weekly “government meeting” (really a com: munity meeting, insofar as the stalf is present). This meeting is an excellent opportunity for patients to exert their own initiative and to use those healthy aspects of their personality always readily available regardless of the reason that might have prompted their hospitalization. “Sick people collectively produce healthy ideas about having a say about theit lies." The patient government meeting allows for a harmonious working together of the two social systems (patients and staff). The linking principle in these two systems should be an attitude of mutual respect, selfcobservation and desire to work con: jointly, assuming mutual responsibility for the at tainment of their respective goals: for patients, an anvelioration or solution of their emotional ailments for staff, a self-pratiying jub. The primary task of our program is not the expression of a “democratic ther- apeutic community,” “equalitarian ideology” or “democracy” in which the responsiblity of every body would actually mean reasponsibility of nobody, for in which agbiguity in the use of power, role duplication and professional identity diffusion pre vents an integrated working together. Our goal is a therapeutic one. All the exploration of group co flicts, administrative constraints, interpersonal diffi-culties. and character problems should have a ther apeutic function related to patients. BASIC FUNCTIONAL PREMISES, Jn this program, careful attention is given to 1, Delegation of authority for specific tasks on the basis of professional background, expertise skills, experience and staff motivation. 2. “Integration of professional workers (ocial workers, nurses, nursing assistants, psy: chologists. doctors, ete.) into teams is directly dopendent on the interactions of people who are different from each other. The aim is not to obliterate these" differences, but rather to take advantage of them. in the context of a creative interdependence.” 3. Optimal rote diffusion, functional delegation of authority, and harmonious interdependence are different from role duplication, professional identity diffusion and obtrusive inter dependence 4. Recognition that in all social systems different levels of accountability and vesponsibility exist Every treatment team needs. by definition, 2 leader who has to be accountable and uli mately responsible for every single decision that affects the social system at large or its con: stituents Decision making is the result of a collaborative effort on the part of team members to provide for theit functional leader the fundamental information indispensable to determine ade- quate solutions to particular problems or to outline whieh line of behavior the team should follow. There is a difference between “par. licipatory decision making” and “decision by consensus within the team,” The former maxi mines creative interdependency, avoids am. biguity and makes the team leader clearly accountable and responsible for decisions made. Decisions made by “democratic consensus” are ‘not necessarily the healthiest anes: they foster ambiguity, create diffusion of professional iden. tity, dilute responsibility and abolish account. ability for decisions made, Democratic con: sensus alleviates the “uncertainty” of the leader who might find therein a refuge for his in- security on the safe grounds of “It was a team Uceision . .." Ideally, patients should play their ‘own role in “participatory decision making.” bbut the leader or staff member to whom authority has been delegated needs to keep in ‘mind that decisions are dictated by a thera Peutic goal: eg. a consensus of the patient system might nol necessarily be a therapeutic tone. Here the staff has the final veto pawer to challenge the consensus, if such consensus was 24 purpose. Not that is democratic ot decided by freed-of-interpersonal- conflict conseisus reflects effective decision not clearly a at fulfiling 2 therapeutic sharing." 6. Our program wee for an optimal balance between the eftremely regimented, all giving Program that fbsters pathological dependency and apathy in tom stalf and patients and the “therapeutic community” which would be beneficial to the neurotic and borderline but which wouldn't reach the severely regressed Patients. Our focus is on the biological and intrapsychic, as well as on the interpersonal: on the small, as well as on the large, social system ENTERING THE HOSPITAL Psychiatrie illness can be the last result of a combination of factors, from interruption and dis tortions of growth, developmental, or normal mature tional processes to physical illness, marital or familial conflicts, and socioenvironmental strains. There is never @ single or simple reason for @ psychiatric itiness. But, by the time a patient comes to the hospital, his coping devices have been taxed beyond his capacity to deal with his particular group of difficulties, Except for a few cases, coming to the hospital should be seen as the beginning of a retuen to health rather than a religuishing of a person's efforts for a more satisfactory way of life, his right of self;determination, and his responsibilities Oftentimes when a patient comes to the hospital, out of inner despair and feelings of having failed outside, he tends to underestimate hit wn actual healthy’ potential; thus, he tries to perpetuate the same situation inside the hospital, forcing staft to take over for hitn. Our program is geared (o provide an optimal belance between too much stress on the healthy aspects of his personality and too much emphasis om his illness or weaknesses, If his asets are overly stressed, a clear estimation of the magnitude of his illness could be clouded. The patient might feel that he is not being heard and that the staff is ignorant of or indifferent to his suffering. On the other hand, if his illness is overly emphasized, 2 reinforcement of his tendency to see himself as weak and sick could be fostered. Ils anticipations of being a failure would be corroborated, his demands for support therefore become insatiable, and, afraid of losing support Irom staff, he might resort 10 even sicker behavior Hosimial life always involves certain limitations and constraints which are different from those of the outside world. It is the responsibility of both social systems, staff and patients, to create the most healthful environment, respecting each other's needsand abiding by certain rules and regulations. Theres Fore, no member of the large hospital system should be allowed to go on his own in an individualistic trend “doing his own thing” without being con: fronted by the fact that his behavior affects the social system at large, There are differences between the two social systems, staff and patients, as well as differences from one individual to another. But, regardless of role, as long as a person is a member of Ihe same social system he is Forced to interact. and as such he has a shated responsibility and say about the success or failure of the overall treatment program. ORIENTATION AND HOSPITALITY COMMITTEE This committee consists of Four patients, one patient from each of the small groups. Their function is to assist staff in introducing and orienting newly arrived patients to the section. People come to the hhaspital for many different reasons and with different egress of impairment, Some might initially need intensive support; some others would require lesser assistance and might even become, from the be. inning, providers of help to others. Adequate orien tution and information about the (reatment program rut oily reduces the anxieties of the first day in the hospital but prepares the patient to discuss the expectations he has for his present hospitalization, ‘TREATMENT GOALS (On the first day, if possible, patient and staff should discuss treatment goals together. Some pa: tients come to the hospital with very unvealistie and randiose goals. Some others, on the contrary, feel that they don't even deserve to be trcated, Snmetimes thus feeling is part of their illness, sometimes. the result of misinformation or simply inadequat fercals. If uncealistic goals are not “tuned down” and hniaiched with the actual potential and limitations of the treatment program, the patient would be allowed to build up illusions that won't be able to be fulfilled later un. a situation which always leads to a mutually unsatisfactory end? The patient, disappointed be- Gause of unfulfilled treatment goals, might then accuse the staff of being incompetent or unconcerned about his illness; the staff, in turn, might feel Psyeliatric treat wlves the patient in an active role: he has lo joi forces with his potential “helpers,” staff and other patients, forming a therapeutic or working alliance with them.” rustrated because the efforts did mt bring about a successtul outewme, But, more often than not problems arise not se much because 4 set of realistic goals has not been formulated but because the ways ‘or modes of achieving them have not been clarified. Psychiatric treatment, unlike others. involves the patient in an active ole: he has co join forces with his potential “helpers. staff and othet patients, forming 2 therapeutic’ of working allinee| with them. The patient ts helped to take a lock atthe active role of his own contribution to the very situation (illess) that he is in. Moreover, he has tb identity himselt etivly with the modes or technighes of helping him S0 that he internaizes them, and|then he ean take ver and go on his own, This view contrasts very much with the misconceptions of seeing oneself asa purely passive victim of Tate or citeumstances or tnevely asa passive recipient of treatment (pill, shots, fe). Exception is made, ofcourse, for those illnesses of 2 clearly organic, hereditary or constitutional nature ‘THE PSYCHIATRIST’S ROLE. Hospital treatment is 2 24-hour endeavor which involves the participation of different mental health workers (psychiatrists, nurses, nursing assistants, psychologists, occupational therapists, social workers, te.) as well as the paticnts themselves. Usually, if a patient comes to the hospital, the brief individual or group appointments with his doctor or mental health. workers have not sufficed to contain his emotional illness, Therefore, hospitalization provides a combina- tion of therapeutic resources (protective atmosphere, social laboratory, groups, medications, occupational and recteational activities, vocational counseling, etc.) which are mixed in different proportions according to the patient's needs. To assume that help will come solely “from individual appointments with doctors would not only be deceitful but would represent 3 misuse of hospitalization. Help will come out of 2 maximum and complete use of all those hospital resources that the patient didn’t have outside. The psychiatrist's task, among others, is to coordinate these resources so that patients take full advantage of hospitalization. SMALL GROUPS Upon admission, the patient is assigned to one of the sinall groups, There are four groups, with seven to ten members in cach group. These ate “group living, task or problenvoriented groups.” Their task is to explore certain issues cg, What brought the patient to the hospital? How can it be understood? What is the patient thinking, feeling and doing about it? What is the rgle of his own contribution, ifany, to the very situation he is in? How can he be helped to, overcome his difficulties? What is he planning to do when he leaves the hospital? How is the patient using for not using the hospital?.What are his treatment goals? How does his behavior affect the hospitalsystem and vice versa7* Patients are also able 10 help thers with similar problems, experiencing a deep satislaction in helping others to overcome suffering they themselves are going through or have ex. perienced. Other patients, however, might have diff. culties in recognizing syinptons hecause they are so ‘uch at home with thenselves.> The group provides an atmosphere for an open, ‘objective exploration of one’s own life style, weak: siess and assets. Each small group meets for one hour four times weekly. One staff member is assigned to cach group as a leader. Each group also has, (on a rotating basis), a patient chairman and a secretary ‘The function of the patient chairman is to work closely with the leader, coordinating the overall functioning of the group. For example, he might Prepare an adequate sgenda for the day, making umself available to those patients who mi some difficulties in communicating their problems and, in general, safeguarding the “group's working ailanev.” The secretary's function is to Keep a record bob the group process WARD PATIENT COUNCIL AND COMMUNITY. MEETING A patient council is formed by all the patients in the section. A patients’ president, vice-president, and secretary are elected every four weeks. Their function 's 10 preside over the weekly community meeting which also includes staff members, The elecied Patients’ president should have an agenda prepared in advance, which usually includes such items as an. ‘houneements or information relevant to the entire Section, introduction of new patients, special prob. loms which sffect both social systems (staff and patients). new uerivals and departures. proposals ete. ‘A clear distinction should he made between the Iwo levels of discussion a higher level diseussion which takes place m the community meeting, and a lower level discussion which takes place in the small groups The higher level discussion in the community ‘meetings includes only issues of general relevance and significance whose nature is such that they affect of influence the overall organization of the section ‘social system) at large, For example, while it might be quite pertinent to discuss a patient's propusals for 4 picnic, problems with the ait conditioning, or the behavior of Mr. X which threatens the stability of the treatment program. it would be suite impertinent and Imipraducive to diseuss the marital conflicts of Mrs 7 ut the request for a pass by Mr W. These items Dbvunusly should be discussed! at tower level, in the sama yuo, Fhe communtiy meeting represents a tox tot pen discussing and communication between the two tal systems. patients amd safely fe ay Aitiiude ol self alservation and sespect fie eneth cther’s assets and weaknesses. Both patients and stalf should work within the context of a creative inter ependence, avoiding the transformation of the eom- ‘unity meeting into a Battlefield, where some might Fidioule others, accusing each other of not Fulfilling their needs, The task jis to join efforts and to ttngush'2 poston of nase pesy pendency (“you give hme, you tell me"), Such profound dependency paralyzes, incapacitates and hinders personal growth, In the’ small groups, help comes from self exploration, confrontations, clarifica- tions, sometimes insight. support, and encourage ment, In the community meetings, help and growth for both patients and staff come from learning through participatory decision making, considerations for action, exposing oneself to mistakes, and the gratification obtained out of actively sharing respon- sibility, Both patients and staff work within the context of a creative interdey ing the transformation of the com munity mecting into a battlefield . ndence, Staff should assume responsibility for providing instructions, support and necessary structure to the Patients’ council, im order for a constructive com munity meeting to tke place, but without in fantilizing the patients or giving the impression that staff always has the last word, Often all patients need are suggestions and recommendations, based on infor tion the staff has available and that patients ignore. By simply putting this information a¢ their service they arc wuided to a wise judgment and the best, most appropriate solutions for their problems. On the other hand, staff shouldn't hesitate to exert their own therapeutic authority in raising objections for even in vetoing a course of action that might not be geared to fulfill the purpose of the community ‘meeting, provided they make clear their rationale to avoid sounding arbitrary. AUTHORITY, DELEGATION OF AUTHORITY, AND FINAL VETO POWER A program which relies strongly on optimal role Aiffusion, 28 opposed to role dup delegation of authority, a8 oppused to averlapping of functions and blurring of authority, and creative Stalffpaticnt interdependence isa program that in vites imter3ystemie (between patients and staf) and Intrasystemnie (among staf mciubers) tensions al Ai(fculties with tepatel te sharin power, authiity anil responsibility ® Thetclore, if iv maulatery tat the dhistibution i authority ts delegation, and the depository of vetw power fis making final decisions ion, Funetionalbe elearly defined, outlined and made known to both patients and staff. Problems do net arise from a clear spelling Out of a Wleearehial functional assignation of authority aid power (Functional assiguation is bestowed on the basis of the necessary expertize, Knowledge, personal skills, tiiaing aud motivation (@ accomplish the assigned work). Rather, problems do arise from a lack of a clearly defined body-system in which authority, power and responsibilities are openly recognized On a psychiatric ward, the personnel have dif ferences in Ueining, responsibility, accountability, status and function: it does no good to pretend these differences do not exist.” Undefined leadership. added 10 the lack of clearly defined role-expectations and tasks, promotes the reactivation of primitive object relations and transforms a working group into a “tegressively chaotic group-dynamic-lke situation,” tnvolving both patients and staff. This situation creates ambiguity and confusion, dilutes. respon sibility and accountability. brings about primitive anxieties, and makes for a chronic, all-pervading systenue tension which reduces performance and is ‘mutually contaminating and reenforeed between the two social systems, staff and patients.® Authority and power ate also delegated (o patients whi are encouraged to be involved in “participatory cision making.” While it is highly desirable that the consensus meet the staff's approval, the staff reserves their prerogative 10 exert theit veto power when called for by irrationality or evidence of usespensibility. The staff shouldn't forget. though, that they are not immune to ictationality and therefare they need co fuster a continuous attitude of | sellciticism and test out their own reactions with bother members of the team. Optimal. sound and real delegation of authority to patients as opposed to “limited, unsound, and thus just token authority” includes by necessity a sense of reality. That is, the reality of the hospital seiting imposes by definition specific social, administrative and legal constraints, different from those outside. The purpose is to create a more humane and intelligent atmosphere than the bone in which the patient became sick. rather than (© sumulate the outside world, 1f the hospital fails in providing this, then “it ceases 10 be a hospital." SPECIAL GROUP MEETINGS INVOLVING THE SMALL GROUPS OR THE WHOLE SECTION. Special group meetings (usvally small groups) are those called for by extravedinary situations at any ‘cher time than the regular daily one, Circumstances: iat prompt a special group meeting nught be, far example, @ suicidal patient who needs une-to-one watchfulness, use of the Quiet Room for a group member, temporary closing of the entrance door 7 while careful deliberation of necessary measures for its sale reopening take place, ete. Special meetings are called by the leaders of small group (a sta member) amal/on by the small group's paticn}-chairman (under staff approval). Active participation of patients, joining their efforts with staff to take care of a group, moniber by reinforcing structure and providing sup. port for him during a crisis, if] intelligently and responsibly done, reconciles multidimensional thera peutic purposes. But if staff only relinquish their own responsibility, simply delegating it to patients, then erapeutic creative interdependence becomes the name for irsesponsible abusive exploitation of pa- tients covered up under the flag of therapeutic intentions. The patients’ needs ought to be di tinguished from those of the staff or the institution.® A truly therapeutic staffipatient working relation: ship, if done within a mutually responsible and carefully planned framework: 1. Allows the patient to identify, internalize, and hopefully structuralize within himself the healing, helping aspects of these relationships 2. Invites the patient (o assume responsibility for taking care of others, the very kind of respon sibility that previously, out of despair of for diverse reasons, he had given up-c.., taking care of himself and his family: 3. Brings forward those healthy aspects of per: sonality functioning that patients have regard: less of their reasons for hospitalization; 4, Shifts his concern from stagnating self-absorp- tion to concern for others with whom he lives and those with whom he will live outside: and 5. Maximizes exploration of one’s own roles, expectations, and contributions (good and bad) within the social system. Internalization of healing, object relations as op posed to defeating, mutually destroying ones: 3s- sumption of responsibility instead of abandoning it; fostering progression rather than regression: pro- rmoting mature concern for others (object-reiatedness) rather than pathological narcissistic selfencapsulated absorption; exploring actively one's own con: tributions to one’s own suffering oF a given situation instead of denying them -all these elements should be eagerly sought, therapeutic intentions. ‘These therapeutic aims pave the way toward a solution of the breakdown in the patient’s control function (ego), strengthen reality testing stimulate personal growth and enrich the self. Often this is all a patient needs 18 come to grips with the crisis that brought him to the hospital. Healthy patients might need assistance solely for the removal of temporary critical obstacles to their growth; once these are removed, patients can go on their own and pursuetheir life goals. Here trustfulness in the capacity for self growth is mandstory'® (the “school of ersis intervention”). For others, hospitalization is just a temporary amelioration of symptoms (the so-called “school of patch-themup.and-dismiss"): for some cases, and whenever hummanly permissible and feas: ble, it represents + preparatory period for further ambitious exploratory psychotherapeutic endeavors (psychoanalytically-oriented schools), Moreover, and unfortunately for some cases of “psychological can. cers,” hospitalization provides at least some palliative alleviation (the custodially oriented approach). There ie no plaee for shame or commiseration in aecepting limited. non-ambitious. yet more reatistic {weatinent goals fora given paticit ifthe nature of the disease itself and the sociveconomic and environ mental constraints so determine, Mature concern about patients includes» sense of reality." Actually, the team’s efforts are liable to entor in both directions: A) Failing to give as much treatment as is needed to a patient who could make good use of it, thus prematurely closing further avenues of growth Often this i the result of ignorance or inadequate Psycho-social-biological diagnosis. Another reason for Premature dismissal is just “statistically, jealous, ‘apid-tummover pruritus” but at a high cost to pay “recycling the same human material time and again through @ higher ceadmissions rate.” B) But one is also liable to lean toward the other extreme of the continuum, “therapeutic tenesmus,” Le, withholding 2 patient beyond what is realy necessary. striving for ambitious. ill-defined. altruistic yet unrealistic goals, and foiling to separate one’s own goals From those of the patient himself and/or those dictated by a particular situational reality. If in. psychoanalytic treatment, treatment goals need to be distinguished from life goals, this is far mote mandatory regarding hospital treatment.!? A CLINICAL VIGNETTE A clinical vignette might serve the purpose here of clarifying working principles outlined so far. Mr. X is & middle-aged, threestimes-divorced patient with a longstanding history of repeated hospitalizations due to periodic overwhelming, all-pervading anxiety states. chrome depression (really chronic boredom and Tife emptiness). polymorphous neurotic features and polysystemie somatizations, in an infantile hnareissishe character structure Previous records Gescribe him a6 a chrume collector of injustices, who indiscriminately complains about the hospital but ssho Keeps coming back because he thinks he has the to be Heated (which he misidentities with unquestioning care, demands for pills, dkagnostie workup, and insatiable hunger for support and attention). One day during» special small group meeting called for a severely depressed patient with overt suicidal risk, Mr X's. patticipation was re 28 quested to provide one-to-one watchfulness. le im mediately refused. arguing thal he needed far more help himself, that the staff was exploiting him, and “besides. why should I take care of others if nobody gives a damn about me?” Faced with a situption like this one, two courses of action, among others, might follow. Typically, some- times the staff_member in question might have possibly become identified with the projected, cruel, “bad.” depriving, splitoff, partobjecis of the pa tiont’s self (projective identification). Consequently. ‘out of guilt feelings, and “readily buying” what the patient said, the staff member (leader of the small group), relieves Mr.X of is responsibility as member of his group, and later complains to his supervisor, "... we are not doing anything for Mr. X we are not really helping him, he is quite depressed and needful as ever.” A course of action like this would only have corroborated Mr, X's impression that he was right in feeling exploited, deprived and unloved, justifying once more his tendency to see himself as the passive victim of an unfortunate fate. It would offer a fitting complementary pathological relationship, allowing the patient to tecreate, reen: acting within the hospital in his relationships to staff the same kind of pathological interpersonal relation ship internalized in his past. This patient would succeed in splitting staff into “good” (those who “really understand his misery") and “bad” (those who “push him around,” deprive him of love and exploit him) The course of action which actually took place however, was as follows. The leader of the small group, who happened to be a nursing assistant. strongly seconded by the patients’ chairman, invited the group to react to Mr. X's refusal to participate in taking care of a potentially suicidal group member. ‘The group at frst hesitantly and later more openly began to confront Mr.X with his narcissistic self centeredness and rather childish attitude toward a peer in distress. There were other comments about envy and lack of concern. The leader then in a kind but sincere way put together the central theme in his intervention: “I wonder if your feelings that nobody gives a damn about you have to do with the very rejection with which you have treated your com- panians?” Following this confrontation, Mr. X half: heartedly accepted taking turns in watching the potentially suicidal patient, Thereafter he becaine less overly preoccupied with his own physical symptoms nd asked for 3 decrease in his medications, arguing that perhaps he was having side effects from them: besides, he felt that “dope has never done anything good for me.” He became more accessible 10 the overall treatment program anid (wo months later felt freed of anxiety and ready to start with a new job opportunity. During the lust weeks of hospitalizationvolved mn confronting avother patient with what he felt was “infantile demandingness” on his part. Was he only “patched up?” Yes, but al least he was a step ahead in the direction of becoming a real psychiatric patient sather than just graduating from the program as an excellent candidate for future recyclin it was reported that he had bewme actively i The approach followed in this clinical example accomplished the five therapeutic intentions outlined: above 1 Mr X was invited to share responsibility in taking care of another person; 2. Ih self-defeating infantile narcissism was shaken up 3, Progressive trends rather than stagnating regres: sive anes were called for; 4. The tole af Me. X°s contribution to his feelings of eing unloved, deprived and exploited was explored 5. Moreover. “embryonic healing object-rlations™ 3s opposed to pathological complementary ones were offered to him, which he seemed to have anternalized (sieucturalized”) and later on began to apply to his own hie ‘Was the nursing assistant's intervention an inter pretation? No. not in the sense of unraveling an tuncanscious genetic root, but it was an accurate confrontation, Was it just a hereand-now oriented Intervention? Not necessarily either, for patients do tw the present what they have learned to do in the past, patients relate to others "here and now” in the same way that they relate toward significant persons in thew “there and then.” Iv these groups, no attempt is made to find out ultimate genetic or developmental nor to indulge in a detailed reconstructive working through of an intrapsychic confit. Rather, the emphasis is on the disturbing remnants uf earlier tternslized ubject-relations that are still active and pera and clearly observable in the present Regular and speetl group meetings provide an excellent social laburstury for exploration of objeetrelations.. In these groups, they become readily avcessible and demonstrable, In additinn, sueh groups have the advantage of providing structure, if necessary, to prevent “therapeutic acting ut.” Further, such an anprosch avoids the perpetuation of splitting mech: anisms that oftentimes happens when exploration Takes place only in the therapist's office “real good treatment” in the office as opposed to the “bad one™ in the ward of vice versa the intimate. ‘The ability to use one’s own self as a vehicle, for {roatment at all levels and in one’s relations to both, paticnts and staff in a program like this has more to do with: | ‘A clear detinition of the tak and overall philosophy of a treatment progr}: + Adequate clarification of role Expectations at different levels: { + Firm conviction (not to be confused with rigid dogmatism or loyalty by ignorance) about what one is doing: + A-stable and integrated concept of one's self as well as a stable and integrated concept of others in relationship to one’s sc, + A dlear definition, delegation and distribution of authority and accountability thas less t0 do with: + Knowledge emotionally unintegrated with prac- tice, inherited from the classroom; + Discipline, titles, grading, status or elitism; + Frozen, stultifying seniority, ie., seniority that doesn't bring about more expertise and an enrichment of the self but rather an impoverish- + Assigned but not practiced roles: + Pseudo-altruistic but distant concern about patients Optimal use of staff talents and abilities in presenting a cohesive, stable and consistent “thera peutic front” which reflects at all levels and regardless of discipline the overall philosophy of a treatment program is different from “wild role mobility,” €.. allowing social workers 10 become junior psychia trists, psychiatrists to become junior social workers, nursing assistants to become nurses, etc.'? There isa need for different role expectations; it is these differences that make a team a team, I is our responsibility 10 educate and train those subordinate disciplines that we supervise within a planned framework. To use them otherwise would only be giving them flattering lip-service credit for what they are doing aimed at making a virtue out of a necessity, ie.. the shortage of professionals. More over, how could we accuse them of apathy and negligence, when that apathy and negligence could be a reflection of our gwn failure to communicate our purposes and provide them with an adequate educa tional backing?REFERENCES Kernberg. Otto I, “Psychoanalytic Object Relations Theory, Group Processes and Administration.” un published paper Falck, Hans $., “Indvidualiom and he Psychiatiic Hospital System: The Problem of Professional Autonomy,” prevented az a Forum Lecture in The Menninger Foundation's Department of E¥ucition, April 15,1970. Ticho, Ernt, perso communication Farell, Dennis, “Development of @ Therapeutic Com: munity, Pat 1," presented at C.F, Menninger Memorial Hospital, Apri 27,1972, Ticho, Ernst, "Factors in the Placement and Acceptance ‘of Patients for Inévidual Psychotherapy.” panel discus: sion for Psychotherapy Service, The Menninger Founda. tion, Api 17, 1972, Schiff, Samuel B., "A Therapeutic Community in an Open State Hospital... Administrative Framework for Social Psychiatry.” Hospital nd Community Psychiatry, 20(9), September, 1969. 1, ere. Marvin ¢The Therapeutic Community: A Critique," Hospital and Community Payehisiry, 2313). Moreh, 1972 Bonn, Ethel M., "A {Therapeutic Community in an Open State Hospital... Adminstratwe Therapeutic Links” Hospital and Community Prychtarry, 29(8), September 1968. Gottman, Books, 1961. Ticho, Gertrude, “On Self-Analysis," International Jour ral of Psycho-Analysis, 48:308-318, 1967, Kemnberg, Otto F, “Notes on Counter Transference, Journal of the American Ptychoanalytie Anociarion, 13:38:56, 1965 Ticho, Ernst, “Tesmination of Psychoanalysis; Treat: ment Goals, Life Goals,” Paychoanaiptie Quarterly 41318333, 1972 Ane atten Cy, No Yor: Anche Falek, Hans S., petsonal communication.