Co-constructing a Conceptual Understanding of System Enactment.

Abstract

System enactments are co-created phenomena characterized by confounding and emotionally charged multi-person interactions that emerge through the convergence of patients' complex psychopathology, staff vulnerabilities, and the organizational dynamics of the clinical system in which all are embedded. There is ample literature about the psychoanalytic construct of enactment in the therapeutic dyad. Though systems-based clinicians often experience system enactments which transcend the dyad and occur within the projective field of the system, there is no comparable literature that discusses this phenomenon. This paper describes a qualitative study that investigated how psychodynamic clinicians understood the phenomenology and impact of system enactments on clinicians, treatment processes and organizational climate. Major themes were identified through qualitative analysis of the data. The following four key findings were distilled from the resulting themes of the study's two research questions: (1) Clinicians conceptualize system enactments from a classical perspective; (2) System enactments have an experiential impact on clinicians in the domains of affect, cognition, behavior, and physiological arousal, which may be related to secondary traumatic stress responses; (3) Clinicians demonstrate a collapse of mentalizing associated with ruptures in the patient's treatment, conflict in the working relationships between staff, and problematic organizational dynamics; and (4) Interconnected and reciprocal interactions among all levels of the system including patient subsystem, individual staff subsystem, intra-staff subsystem and organizational subsystem, are shaped by the impact of system enactments. A conceptual understanding of system enactmentis outlined, and implications for clinical social work education and practice, organizational policy-making and research are addressed.