The Staff Member's Crisis of Control in Psychiatric Residential Treatment:

Abstract

A difficulty encountered in the smooth operation of a psychiatric hospital or residential treatment center is the conflict between freedom and nonpunitiveness and the need for adequate control. Authors examine staff members' difficult adjustment to an open psychiatric hospital for adolescents which has few external controls. Staff members experience a crisis of control which may result in: (1) misuse of standard procedures to gain control; (2) possessiveness of patients; (3) projection of the need for control so that it is seen in neutral situations; (4) regression in the face of countertransference; (5) control of employees below them in the hierarchy. Institutional contributions to this crisis include: (1) the premature requirement for staff competence which results in the therapist's inappropriate reliance on the patient's behavior to reflect it, and (2) the influence of the psychoanalytic model and psychoanalytic neutrality which can make therapists and other staff members feel helpless and irresponsible. Authors stress tolerance for this crisis as an expected phase of the enculturation process for staff members. Staff must become aware of the countenransference process (not only so that they can become reflective and disengage but also because it provides them with a healthy respect for irrationality). Experience will aid front-line staff in realistically estimating the severity of the patient's pathology, which is often under-estimated. A peer evaluation process and staff support groups are recommended as a medium for enculturation which permit the staff member to compare personal attributes with those required in the milieu.