Structure, Self‐Regulating Sequences, and Institutional Third Parties in Therapy: The Veterans Administration as a Model

Abstract

This article examines the structural organization and sequences of interaction among therapists, institutions, and patients and their families that contribute to the problem of institutional dependence. Our contention is that when patients have become dependent on an institution for the livelihood and/or for the stability it represents, they are only one part of a systemic relationship characterized structurally by enmeshed boundaries, and sequentially by self-regulating feedback loops. We use this premise to outline the nature of the enmeshed transactions in patient-therapist, patient-institution, and therapist-institution relationships. Family interfaces with this triad are also addressed. Sequentially, we outline the interactions among patient, family, therapist, and institution that lead to hierarchical incongruities. These sequences tend to produce self-regulating feedback loops that perpetuate and maintain the structure of the system and its patterns of interaction. The final part of this article demonstrates how we strategically use a therapy team to manipulate the hierarchical incongruities and, hence, the recursive complementarity, that characterize the interactions between and among the members of this suprasystem. Besides manipulating the role of the therapist through team intervention, we also present several paradoxical and structural interventions that have been helpful when institutions have become third parties to therapy.

Therapy pitfalls with Vietnam veteran families: Linearity, contextual naïveté, and gender role blindness.

“…The larger context of Vietnam veterans has likewise only recently received attention. Fry, Swanson, and Jacob (1987) examined the Veterans Administration (VA) as the significant contextual variable in treatment of Vietnam veterans. In their study they described the VA as a system burdened with complicated issues of secondary gain, in which the "VA becomes not only a treatment facility, but a source of potential or real income" (p. 225).…”

“…However, when Vietnam veterans are involved in other concurrent therapies, the family therapist must broaden the view of the target system from that of the Vietnam veteran family alone to acknowledge the impact of these treatment systems. As has been shown above (Fry et al, 1987) therapy with Vietnam veteran families must be informed by awareness of the important impact of the VA adjudication (compensation) and treatment systems on the target families. Fry et al (1987) recommend that compensation issues be addressed openly and that efforts be made to reduce the perception of therapist-VA fusion: "We emphasize throughout the therapy that the therapist and the VA are separate and may have conflicting goals for the patient" (p. 230).…”

Compensation and psychic trauma: A study of Israeli combat veterans.

“…In recent years, more complex theories have been presented to explain the link between compensation and the psychological sequelae of traumatic events. Models proposing that the course of recovery from PTSD may be influenced by a number of factors besides financial ones focus on the interacting effects of the family, legal, and medical systems on maintenance of symptoms and on recovery (Frey, Swanson, & Jacob, 1987; Noy, 1975; Rickarby, 1979; Robitscher, 1971; Stagoll, 1982; Tarsh & Royston, 1985; Weighill, 1983).…”

Post-Vietnam gender role strain: A needed concept?

“…Veterans receiving the PTSD diagnosis face a second set of problems, which are related to the potential for “enmeshment” in the Veterans Administration (VA) system (Frey, Swanson, & Jacob, 1987) and “disengagement” from family (Harrington & Jay, 1982). The common practice of segregating treatment of Vietnam veterans has been criticized as provoking the creation of a “minuscule ghetto-like environment [that] isolates the mal-adjusted veteran from society and seems to reinforce deviant trends” (Fleming, 1985, p. 138).…”

“…Last, the more dysfunctional aspects of the enmeshment between Vietnam veterans and the VA treatment system should be altered. The current trends toward alienation of veterans’ families from treatment (Frey et al, 1987) should be challenged through emphasis on gender-sensitive family therapy (Avis, 1986).…”