Multipletreater settings

In inpatient units and partial hospital settings, psychodynamic concepts are of considerable value in understanding the patient's psychopathology as it unfolds in a group setting. Patients re-create their internal object relations in the inpatient or partial hospital milieu. (38) The conflicts that occur in their family context will re-emerge in their relationships with hospital staff members. Through projective identification the patient subtly pressures various staff members to play the roles that are in keeping with the patient's internal world. Hence a patient who has been physically and/or sexually abused by a parent will behave in such a way toward a certain nurse, for example, that the nurse begins to feel abusive toward the patient. The same patient may treat another nurse as an idealized rescuer figure, eliciting loving and protective feelings from that nurse. This form of splitting (38) may create extraordinary conflicts between staff members over the best treatment approach to the patient. Therefore failure to attend to the transference-countertransference dimensions of the milieu treatment may lead to a total disruption of the staff members' capacity to be effective with certain patients.

Moreover, individual patients often act out covert staff conflicts.(39) Psychodynamically informed hospital treatment may help to identify these conflicts and allow staff to process them in such a way that the patients no longer need to enact them. When covert conflicts between staff members become overt and open to discussion, the patient's disruptive behaviour often settles down.(39) This observation reflects how the dynamics of the patient group and staff group often parallel each other. The psychodynamic clinician also understands that individuals behave differently in groups than they do alone or in a one-to-one context. Powerful group forces, such as scapegoating, can be recognized and processed so they do not become destructive to treatment. Similarly, the patient's recurrent problems in groups can be diagnosed, in part, by a careful study of the transference and countertransference responses.

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