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

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.