– Conscious and Unconscious Levels of Resistance when Members of New and Old Therapeutic Paradigms Communicate – A Discussion of Problems Arising in the Communication of a New Therapeut

A Discussion of Problems Arising in the Communication

of a New Therapeutic Approach for Schizophrenic and Borderline Conditions
Andreas von Wallenberg Pachaly Düsseldorf,F.R.G.

Free Counseling Center for Psychotherapy, n.g.o., n.p.o.


This presentations wants to foster a discussion on the chances and problems
				that arise, when creating a community based holding and containing environ-
				ment that is constructed within the community and that continually strives
				to integrate its participant patients into the community.
				That means to integrate the split off and fragmentated experiences of the
				participating patients in order to counteract the ongoing splitting of bor-
				derline-patients, and even scattered and fragmentated experiences of
				schizophrenically reacting patients and thus support the maturational pro-
				cess of the patient.
				The authors will present the problems they and their team did and do
				encounter in conveying their new approach of an integrated therapeutic set-
				ting, "the therapeutic community within the community" to other profession-
				als and administrative influential policy makers.
				The counter-transference-reactions of the staff of the "therapeutic commu-
				nity within the community" to the old paradigms and their representatives
				are illustrated and discussed as well as the possibilities how these might
				serve as screens for the projection of unacceptable feelings.

The Setting

This model was introduced at last year's conference and I will outline
				only its essentials.
				Usually eight patients of both sexes live together in a flat or in a
				house. The diagnosis of the patients range from severe borderline, extreme
				anxiety patients to schizophrenically reacting patients and psychotically
				reacting patients. Substance abusers are excluded. The majority of patients
				had prior in-patient treatment, about one fourth did have only out-patient
				treatment. About 75% are on psychochemicals at the time of admission. The
				duration of their stay is 3 years, a prolongation of one or two years is
				possible, if it seems of therapeutic value.
				The therapeutic milieu itself rests on four pillars:
				1. Every patient has to participate in two groups concerning the shel-
				tered flat. One takes place in the flat and deals with the organizational
				affairs of the living together, the other one is carried out outside, at
				the head office of the Counseling center, which offers the institutional
				umbrella of the sheltered flats. This groupdynamical group cares for the
				emotional needs of the inhabitants. The interpersonal matrix is perceived
				and a continuing effort is made to make the unconscious dynamics conscious.
				A constant monitoring of the position each patient takes in the flat is
				carried out, motivational work is done, conflicts on all levels, primarily
				in the here and now, between patient, with the institution, with the out-
				side world are discussed, and the violations of rules are discussed and
				eventually resolved.
				2. Every patient has to live according to a structured daily schedule,
				either structured by work, schooling, a day clinic, sheltered work, etc. In
				the beginning, of course it is the frequently hard task of the social work-
				ers to support the patients in structuring their daytime.
				3. Every patient is required to carry out a psychotherapy with a psycho-
				therapist according to his needs.
				The hub of the psychological and social integration takes place within the
				sheltered flat that provides the necessary social energetic foundation to
				promote and sustain lasting personality changes.
				The sheltered flats are guided by a team of social workers trained in
				groupdynamics under continuing supervision. Their prominent groupdynamical
				task is to coordinate and to integrate the patient's various fields of
				learning and his scattered and split up experiences. By motivating all
				patients to undergo group- or individual-, psychosis- or borderline-therapy
				the basis is broadened that the patient becomes able to integrate into
				society; be this by means of continuing education, work, or sheltered work.
				Of course, there do exist quite a few sheltered flats in Germany, but what
				makes the change of paradigm in our view is:
				1. We make use of the group as a community that provides a living-working-
				learning institution
				2. We foster a culture of continuing enquiry within the group and
				3. we try to apply group-dynamical and psychodynamical knowledge and
				approaches to the understanding of the group situation as well as to the
				understanding of the individual patient.
				4. We try to integrate the various split off and fragmented experiences the
				patient makes in his different fields of living, working, and psychother-
				5. And in order to become able to do all this we strive to enforce a set of
				clear boundaries concerning time, place, roles within which a process of
				integration becomes only possible.
				As you easily might recognize, these are the criteria's David Kennard in
				his paper last year discussed as prerequisites for a therapeutic community.
				6. We pursue the goal of genuine structural personality change with so
				called psychiatric patients, who suffer from schizophrenic and psychotic
				reactions and severe borderline states.
				7. And we also adhere to an integrative group concept, that intentionally
				mingles severe and less severely ill patients.
				The institutional framework that has created the conceptual, monetary,
				and personal framework to carry out these sheltered flats is the Free Coun-
				seling Center For Psychotherapy, a n.g.o. n.p.o..

New Versus Old Paradigm

In the main stream German psychiatric as well as psychotherapeutic profes-
				sional community a prevailing attitude towards schizophrenically reacting
				patients, as well as to sever borderline cases, seems to be that these
				"cases" have to be managed a life-long by continuing medication (depot-vac-
				cinations). They have to be managed by shielding them off from external
				stress as far as possible (frequently giving them the status of an early
				retirement) and by putting as few demands on them as possible. We have set
				up a sheltered flat as a therapeutic community integrated into the commu-
				nity that provides on the one side a stimulating therapeutic community and
				strives to integrate so to speak extramural therapies (group or individual
				therapy) as well as efforts to integrate the patient into the working pro-
				cess. Thus we find ourselves frequently in strict opposition to ruling med-
				ical or health-bureaucratic authorities.
				If the two paradigms of care for psychiatric patients would exist com-
				pletely isolated from each other, like paradise island and dessert valley -
				no problems would arise. Though, within many patients, having participated
				in both paradigms, the contradictions evoked by a clash of attitudes and
				approaches alone might stir unbearable tensions.
				But there are numerous interfaces and levels of contact between both para-
				digms. In the case of acute continuing psychotic states, where fragmenta-
				tion of experience and overwhelming states of anxieties are present and the
				security provided by a hospital environment may become necessary.
				Or with so called borderline-patients, who can manage their inner tension
				only by vehemently devaluating, attacking their present environment, the
				entire staff of the sheltered flat and feel themselves compelled to regress
				to a way of splitting where they will try to seduce the hospital personnel
				to engage into an alliance with them against the bad guys from the shel-
				tered flat.

Levels of Interfaces

In this paper we want to discuss the capacity of the staff to encounter the
				Our experience are on different levels:
				1. On the working level, the attempt to integrate the patient into the nor-
				mal working field through places of sheltered work, practices and appren-
				ticeships, and normal work places.
				2. On the psychotherapeutic level the cooperation with individual and
				group-psychotherapists in private practice.
				3. on the level of hospitalization, the cooperation with the medical and
				the paramedical staff.
				4. the cooperation with medical authorities from the bureaucratic and
				political sector.
				5. Last not least, important interfaces are the cooperation with institu-
				tions who operate also with psychiatric out-patients in a sheltered envi-
				ronment, however within the old paradigm.

What Happens to the Staff of a New Paradigm

Already in 1962 T. Kuhn (Chicago, Chicago Press) discussed in his book The
				Structure of Scientific Revolution the different stages new movements and
				new scientific approaches that represent new paradigms go through before
				they become incorporated and treated as if they had always represented the
				mainstream approach.
				When participating in the development and application of a new approach, in
				our experience archaic anxieties are stimulated. The staff member, espe-
				cially when trained partly in the old prevailing paradigm is
				1. not only confronted with the skepticisms or open criticism by represen-
				tatives of the old paradigm, but the staff member is also confronted with
				2. internal anxieties provoked by the fact that he leaves behind the old
				"parental" believe paradigm and does participate in a new one. Of course,
				the unconscious feelings of guilt stirred by this are frequently repressed
				and an exaggerated arrogant attitude is taken towards collaborators of the
				old paradigm.
				I do remember a case, where a staff member was so enthused and thrilled
				because of the "huge human effort made by the community for one patient,
				whom he judged very needy that, when this patient fell back into a severe
				crisis he only could condemn her psychotherapist as absolutely ignorant and
				not caring at all, as even neglecting the patient, though in the end she
				proved to be a well trained and diligent psychotherapist, who was obviously
				more in touch with her feelings of countertransference than this staff mem-
				3. Other vicissitude are that the anxieties are subdued by adapting to the
				point of view that one really does not do anything new or that in this par-
				ticular case a new approach really is not possible, and so to speak one
				excuses oneself for having tried a new approach.
				4. On the other side are not seldom the possibilities and perspectives of
				the new approach exploited to express feelings of revenge against parental
				authorities with whom the old paradigm is identified and seemingly fruit-
				less fights are carried out with representatives of the old paradigm. An
				especially sensitive area for this is psychopharmacological therapy. An
				ideological dispute over its use seems to be well suited to distort the use
				of psychochemicals as a disciplinary ordeal on the one side and an absolute
				neglect of the patients right to be treated medically in an adequate way
				on the other side.

The Paradigm as a Nurturing Mother-Matrix

In general does the new paradigm not provide as much authority and support
				as the old paradigm, where one can say to oneself that one is doing it the
				way it has always been done, how it has proven effective or at least has
				been approved by the major medical, scientific and bureaucratic authori-
				This gives a feeling of security a new paradigm can not provide. It seems
				to us therefore "normal" that members of a new paradigm live in a less
				stabilizing professional environment. Developing a new paradigm also means
				to be in close contact with actual needs of the system and this requires
				open ego-boundaries.
				How do staff members make up for this lack of emotional stability the para-
				digm is unable to provide. In discussing this problem we can differentiate
				between defense mechanisms and coping mechanisms. Dominant defense maneu-
				vers are:
				1. We experience an overidentification and idealization of the new para-
				digm, which of course will only help to worsen problems of communication
				with members of the old paradigm.
				2. We experience the "duck and cover" attitude, which lets people quasi
				ignore and even deny that they cooperate in the realization of a new
				approach, in contact with members of the old paradigm they try to minimize
				existing differences.
				3. And finally we are able to identify members of the so called 5th com-
				pany. They are partly identified with the suspicions, the lack of trust and
				the fundamental doubts of the members of the old paradigm. May be one could
				say they identify with the aggressor. However they do experience the new
				paradigm as so threatening that they do not dare to make their doubts pub-
				lic and to enter into a public intra-paradigm discourse. Instead they do
				act out their deep-rooted feelings of ambivalence and contribute by their
				acting out to the failure of the new paradigm. E.G. they forget to post
				certain papers, where a deadline exists to secure further funding,
				The point we want to make is that the roots for this behavior can already
				be found in the phase of separation from parents and how this human being
				was supported to form and establish his own identity.
				Did this individual staff member experience a holding environment to become
				able to explore life, his environment and other relations and to make use
				of his parents as a refueling base, or were own steps forbidden, guarded
				with jealousy and were feelings of guilt instilled.
				If this was the case we must assume that unresolved feelings of guilt or
				feelings of symbiotic rage are at work too, when such a staff member col-
				laborates in the realization of a new paradigm, this must first be worked
				through, before effective work can start.
				However, if we succeed to assist these staff members to detach themselves
				from their ambivalences and to enter into a discussion with the members of
				the staff of the new paradigm, they can in a constructive way become trans-
				mitters and borderliners, that will help to bridge the communication gap,
				between old and new paradigm.

The Pathology of Intra-Paradigm Conflict-Resolution

New paradigms frequently try to fend off conflicts, repress them and deny
				the accompanying anxieties by fostering a symbiotic feeling of being melted
				with the good part of the world, whereas the members of the old paradigm
				belong to the realm of the evil. From members of Balint groups, who work as
				staff members within the old paradigm, we know that conflict-non-resolution
				by intrigues is a favorite way of coping with overwhelming anxieties,
				aroused in the work with severely ill patients.
				Members of new paradigms melt with phantasies of self-idealization. By
				becoming very provocative, they create frequently the attitude of opposi-
				tion they expect to have to fight. By putting unrealistic demands upon
				patients and upon themselves, staff members, at times, create resistance
				from patients as well as from care-givers of other institutions that seem
				to fend off feelings of helplessness, impotence and despair, originally
				caused by the very patients they endeavor to work with.

The Patient Within the New Paradigm

How do patients react to being a member of a new paradigm.
				1. They either identify, are able to draw strength from this, which gradu-
				ally may be replaced by genuine own strength, or worse cases are not able
				to achieve a realistic feeling for their limits and seem to pursue unreal-
				istic goals and continue to overestimate their possibilities, or
				2. in some cases in times of conflict patients switch sides and identify
				with the old paradigm in order to become able to express their aggression
				against members of the new paradigm.
				The following vignette of Ann demonstrates the case of a severe borderline
				case where we succeeded in establishing a cooperation between two para-
				digms. The patient had been living in a sheltered flat, before she had come
				to us, that was not working like a therapeutic community. She had been back
				and forth between Hospital and sheltered flat for five years, after having
				spent some years in the hospital. In the beginning she seemed to be full of
				hope to become able to change her fate. She underwent analytic group-ther-
				apy and after a year became able to enter a training as a florist. Yet the
				smooth course of her therapeutic success was now and then violently inter-
				rupted by fits of self-mutilation, by abrupt raptures in contact and inten-
				sive withdrawal. At times she felt very suicidal, at others quite optimis-
				tic. Yet on the whole she continued to make progress. In one of the severe
				downs she suffered, she abruptly decided to enter the hospital, she had
				been in many times before. There she started to tell all kinds of horrific
				stories from being pushed too much to have to undergo psychotherapy against
				her will, etc.
				When one of the social workers, responsible for her, visited her at the
				hospital and contacted the medical staff he was received with great reser-
				vation. Only informally he was told by a paramedical staff-member what the
				patient had complained about and in what colorful ways.
				Well, he tried to explain the setting and the therapeutic treatment concept
				to the medical doctor in charge of her and also tried to raise the concept
				of splitting. After a few weeks the staff of the hospital also noticed the
				patients capacity to split and started to be confronted to have to cope
				with it. It was then that staff members of that hospital became interested
				to visit the counseling center and to exchange information but also to ver-
				ify the information they had gotten from all kinds of sources. Like,
				patients are made dependent because they are forced to undergo psychother-
				apy. The therapeutic community represented a sect. People were not treated
				like sick people but like healthy one's and much too much was asked from
				In this case the actual meeting between members of the staff of this hospi-
				tal and the free counseling center could remove some prejudices and estab-
				lish some interest in the integrated treatment approach to this borderline
				The patient at a later point tried to become hospitalized again, but this
				time the hospital staff was more ready to cope with her capacity to split
				and to address the underlying anxieties.
				The case of Tom, also a severe borderline case demonstrated something else
				to us. He too allied the support of the hospital he entered, but he gave a
				such convincing performance of the suffering that had been afflicted to him
				at the sheltered flat, that he got the unconditional and unquestioning sup-
				port of his social worker and psychiatrist. Every cooperation was refused,
				which provoked intensive feelings of hate and aggression in the staff of
				his sheltered flat. The reputation of the entire institution of the Free
				Counselling Center was at serious stake. This was furthermore reenforced by
				the ruling attitude in that hospital that psychotic patients should not be
				treated psychotherapeutically at all. It was only a small consolation, that
				within 6 weeks the situation repeated itself and the patient discharged
				himself to another hospital. There he reproduced the same pattern. Though
				several efforts were made to establish professional cooperation, again it
				was impossible to rally cooperation for the sake of the patient, because
				we did not succeed in overcoming the strong forces of splitting and the
				patient finally left our institution for good.
				In the case of a schizophrenically reacting patient, we experienced him
				reacting psychotically to a degree that we feared for his and his fellow
				patients life. He was thus sent to a hospital and at first taken to a
				closed ward. He came back to "normality" by psychochemicals within a few
				weeks and now was fortunate enough to encounter a psychiatrist who somehow
				held a model of "schizophrenia" that conceded for some social and interper-
				sonal factors in the genesis of it. The patient became very sensitive to
				the different approaches and for some time seemed to be very anxious what
				was right. Later, we were better able to understand the significance of his
				hospitalization. Simultaneously, as the new setting within the new paradigm
				enabled him to get in touch with his feelings of having been hurt, almost
				annihilated in a psychological sense, he himself at times liked to destroy
				the setting and initially was only able to express his anger and rage over
				having been hurt by making use of an orthodox psychiatric hospital.
				In this case it eventually also proved very important that the flat members
				kept very close contact with him and a fragmentation of his experienced was
				counteracted by the integrative striving of his living group and the staff.
				With schizophrenically reacting patients, where it was not possible to
				enlist a benevolent or at least neutral attitude of the hospital staff
				towards our paradigm, we had to make the experience that a further fruitful
				cooperation with the patient was always at stake.
				In another case we had the experience of a rather quite matured patient,
				who had reacted psychotically and was hospitalized. Initially, she was
				heavily drugged. After a few days she became able to protest and openly
				argued in favour of the therapeutic community model she had already lived
				in for two years. During the remainder of her stay at the hospital, she
				became transgressor of borders , and eventually an ambassador, who in a
				certain way took over a bridging function.

What to Do to Succeed?

Many members of the old paradigm have arranged themselves within the old
				paradigm and do follow their daily routine. Confrontation with new ways of
				coping with the possibilities of patients suffering from borderline or
				schizophrenic conditions will always also be a confrontation with the own
				petrification. Defense mechanisms are stimulated, and simultaneously anxi-
				eties are stirred. In order to enter into a useful exchange, it is useful
				to remember that nobody is perfect. Only if people do feel secure and
				accepted is it possible to touch their insufficiency in some areas and
				awake their interest to become open and to explore new ways of dealing with
				I would like to introduce here the concept of "critical mass", known from
				nuclear physics. I found that when a certain quantity of innovation has
				been successfully implemented, members of the old paradigm are stirred to
				violent opposition and destructive forces become awake, because its imple-
				mentation is threatening the own self-concept, but also, because in face of
				the possible success of the new paradigm the internalized prohibition to
				live is experienced as too overwhelming. We recognize these processes also
				in our team.
				Critical mass in another sense means that the quantity and intensity of the
				transference-feelings on a new institution, have gone beyond a degree that
				could be managed by its members. It is an interesting question to what
				degree countertransference feelings respectively have to increase to become
				not any more supervisable. This seems to be the case if the feelings of
				transference are experienced as too threatening and a sort of paranoid
				countertransference occurs, which is not any more useful to sense what is
				going on, but which triggers fears of being annihilated and being
				On an international level Cuba is an interesting example.
				However again these feelings must not be understood only as feelings of
				countertransference towards a hostile environment but should also be looked
				at vice-versa as a projection of an internalized prohibition to life, which
				is projected on the outside, on institutions representing the old paradigm.
				Only by becoming aware of this fact, it becomes possible to take up rela-
				tions to the outside.

Intra-Paradigm Coping Devices

Every two month a large group takes place, where the inhabitants of all
				three existing sheltered flats participate in, as well as the social work-
				ers and members of the board of government of the umbrella institution, the
				Free Counselling Center.
				The large group not only opens a space to exchange experiences, but also
				brings emotions into public that were rather hidden so far, like rage, or
				feelings of helplessness. It also provides feelings of security, by embrac-
				ing the different flats and creating the feeling of one large community.
				The large group is the place, where the feeling of living-culture can
				felt best, because the different groups can perceive each other, become
				perceived by the others and a common border towards people, not living in
				the sheltered flats becomes very well defined. It thus has an important
				function in promoting the growing process of group-boundaries and group-
				identity. It is experienced by some as a critical backbone which gives
				strength to critical members and does help to make hidden conflicts visi-
				ble. It strengthens the institutions group-identity and helps to provide
				new strength to encounter the outside as well as the inside.
				The Role of Leadership
				I remember, when we started our movement for a sheltered flat, we so to
				speak became the target of transferences at the early stage of pregnancy.
				There did not exist a single chair yet and already we were suspected by one
				representative of the city health bureaucracy to plan to take over much of
				the psychiatric care system of the city of Düsseldorf. Was it because the
				potentials of this model had been judged by the psychiatric authorities of
				the city bureaucracy as so overwhelming, or was it because my reputation of
				having participated in the struggle for a human, dynamic psychiatry for
				over fifteen years had earned myself such a formidable reputation? Or was
				this a counter-transference to the messianic aspirations, we unconsciously
				associated with the creation of the new paradigm.
				There do exist, however, transferences of members of the old paradigm on
				the institution of the new paradigm, her staff and her leader.
				One phenomenon that we frequently could observe is that the staff is per-
				ceived as a completely dependent tool of the leader. Thus, their behavior,
				their capacity to take over responsibility, and their professionalism is
				devaluated extremely. The interesting, paradox, and surprising contradic-
				tion is, that to the same degree as the staff is devaluated and the leader
				becomes the object of harsh critique because of supposedly lack of profes-
				sionalism, the institution itself, in some miraculous way, is perceived as
				very powerful, threatening, even omnipotent. Power, wealth, and human
				influence is attributed to the new paradigm, as well as to its leader, that
				really impresses as superman.
				Behind this, we suspect the hidden wish for change, the own feelings of
				impotence in face of the desire for change, and the hidden hope that the
				leader of this detested new institution may be the Messias after all.
				These wishes, of course, are repressed and expressed in some kind of reac-
				We have to discern between manifestations of transference of the own staff
				and of patients of the institution on the institution, and on the other
				hand, transferences of outside staff, institutions and their leaders on the
				institution representing the new paradigm. What we always experience is,
				that the transference on the institution is something archaic, latent, and
				not very easy to grasp.
				By our patients the institution is most frequently experienced either as a
				protective, supportive mother or as a devouring, omnipotent and dangerous
				vamp. The transference manifests frequently in the interaction with the
				staff, but sometimes hits the board of directors and especially the leader
				with full power. The leader seems to be the epicenter of power though in
				reality this may not be the case. The capacity of the staff to work through
				this transference decreases as the staff itself is not capable of working
				through their transferences on the institution.
				Of course, we also should look at the counter-transference the board of
				directors and the leader himself has on the staff and at times also at the
				patients' group. The Laios complex has described one aspect. But this is a
				very structured way of relating. There are more diffuse feelings of coun-
				tertransference, like feeling persecuted, annihilated, betrayed, solely
				responsible for everything.
				Management and leadership are also an art. The classic western leadership
				scheme is one of powerstruggle. The greatest skill necessary is to make use
				of the capacity to win power-struggles. Of course, this results in the need
				for rather hierarchical lines of commands and for rather clear cut fields
				of responsibilities.
				Already T.Main argued that there exists the necessity to clearly organize
				responsibilities and also lines of responsibilities along a hierarchical
				system. This necessity seems to increase as the institution becomes more a
				target of transferences.
				However, another way is to distribute responsibilities according to skills
				and human resources following a paradigm of consense-finding. Here hierar-
				chical structures are not very clear and exist only to a minimum. But lat-
				eral structures are frequent and the flow of information is extremely high.
				This, by the way, is the Japanese paradigm of management, who feel that the
				power struggle paradigm wastes a lot of valuable human resources.
				This paradigm, of course, requires the capacity to look at the world
				through the eyes of the other and requires a low need of the individual
				staff member to assert oneself and a sound sense of personal identity.
				The separation between leadership and the new paradigm seems to be a cru-
				cial point, to what degree the new paradigm is capable of existing by its
				own and to influence the old paradigms. Usually ideas survive, if they are
				worth it, leaders not.
				One crucial problem in this context seems to be, who is responsible for the
				development of a new approach and who gets the merit or whose merit is
				denied. It is like the rivalry concerning the fatherhood of a baby, and
				what happens when the baby becomes of age. It doesn't any longer want to be
				the baby of somebody but a being in his own rights. Maxwell Jones just left
				without saying good by, others never leave and do take the baby with them
				back into their grave. There seems no simple solution to this challenge.


The lust to destroy the innovator seems to promise not only a feeling of
				power, but also the prize of gaining the old paradigm's members applause.
				Main argued vehemently in favour of observing the legitimate and not so
				legitimate needs of members and especially leaders of the old paradigm. It
				was obviously the result of a realistic appraisal of the power-game.
				However, we feel very much, that also within the staff of a new paradigm
				the members are very much split into adherents of the old and the new para-
				digm. We must be aware that this split can go right through one and the
				same person. It is simply naive and in a certain way old thinking to assume
				that ambivalence does belong only to the old paradigm. The leader of a new
				paradigm too, is not free from this split. Thus, there seems to wave a con-
				stant battle between life preserving and life destroying forces, and Wind-
				sor-Conference feels like a good place to reenforce the life-preserving and 

life-creating forces.ic Approach for Schizophrenic and Borderline Conditions

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