Transforming Divisive Dynamics in Treatment Systems: Applying a System Enactment Framework

Treatment systems, such as intensive outpatient programs, partial hospitalization programs, residential programs, and psychiatric hospitals, can be some of the most challenging settings in which clinical social workers practice. Two primary factors contribute to the challenges experienced by clinicians in these settings. First, patients who require this level of care usually present with comorbid diagnoses and other complex underlying problems that make their conditions challenging to treat. Second, system enactments are prevalent in these treatment settings. System enactments are complex, confounding, and divisive multi-person clinical encounters that manifest through the convergence of patients’ complex psychopathology, individual staff vulnerabilities, intra-staff dynamics, and the organizational dynamics of the clinical system in which all are embedded (Morey, C. M. (2022). Clinical Social Work Journal, 50(2), 170–182). Effective clinical practice in these settings requires knowledge and skills based on conceptual frameworks developed explicitly for treating complex patients in the multi-dimensional context of a treatment system. This paper introduces a conceptual model, referred to as a system enactment framework, which delineates four steps to guide clinicians in working through divisive and other challenging dynamics in the context of system enactments. A pathway to optimize clinical practice is illustrated by the application of this framework to clinical case material. When recognized and engaged, these enactments have significant clinical utility in systems treatment. This approach aims to enhance patient outcomes by repairing alliance ruptures with patients, restoring intra-staff functioning, and re-establishing equanimity within treatment systems.