Magic mountain - Andreas SG.vo Wallenberg Pachaly

Andreas S.G. von Wallenberg Pachaly, Düsseldorf, Deutschland

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Ebene 10
The Magic Mountain in the Community
A Paradigmatic Change from Sheltered Living in a Flat towards a
Therapeutic Community within the Community
Andreas von Wallenberg Pachaly, Duesseldorf
 Free Counseling Center for Psychotherapy, a N.P.O., N.G.O
This  presentations wants to present a model of a therapeutic community that  is constructed within the community and that continually strives to  integrate its participants into the community, in order to counteract the ongoing splitting  of borderline-patients,  and  even the scattered  and  fragmentated experiences  of schizophrenically reacting patients and thus to  support the maturational process of its inhabitant-patients.
The Setting
There  exist three groups of eight patients of both sexes.  Each of them  lives  in a flat or in a house.  The diagnosis of the patients range from severe borderline-conditions, extreme  anxiety patients to schizophrenically or  psy÷ chotically  reacting patients.  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 ther÷ apeutic value.
The therapeutic community itself rests on four pillars:
1.  Every patient  has  to participate in two different  groups. 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 Coun÷ seling  center, which offers the institutional umbrella of the therapeutic com÷ munity within the community.  This groupdynamical group cares for the emo÷ tional 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 and institution, or the outside world are discussed, the violations of rules are acknowledged 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  workers  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.
4. Every four weeks patients of all flats, the social workers and the thera÷ peutically trained board members (group-analysts and family-therapists) par÷ ticipate  in  a  large group. This group works continuously to strengthen  the therapeutic cultural space and provides a feeling of security by giving birth to a feeling of one big community.
The  large group is the place,  where the feeling of a living culture can be transmitted  best,  because the various subgroups can percieve each other and  can be percieved.  A clear boundary is defined towards the people  out÷ side the community.  The large group's function is to support the growth pro÷ cess  of  group-boundaries and group-identity.  At the same time it  strength÷ ens the  group-identity of the "therapeutic community within the community" as  an  institution and  provides  its member-patients  with new  strength  to encounter the outside world as well as their inner world.
The  hub of  the psychological and social integration takes  place  within the living group of each flat,  which 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 continuous supervision, who conduct the groups men÷ tioned  above. Their prominent groupdynamical task is to coordinate and  to integrate the  patient's  various fields of learning and his split  up and  even fragmented experiences. Another important task is to make transparent how each patient reenacts and puts on stage his basic conflict and to support the group  in creating an atmosphere of curiosity and inquiry.  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  soci÷ ety; 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-wor
  king-learning  institution and  of  the groups  and  the large  group  of            all three groups as a therapeutic culture.
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  patient's various  split off  and  fragmented       experiences of his different fields of living, working, and psy-
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.
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 intention
  ally combines 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.P.O., N.G.O
The Role of the Social Worker
The social worker,  working in the therapeutic community within the com÷ munity have to operate on five levels.
1.  They must check reality and at times give support to cope with reality demands,  in  so far, as the patient lacks the capacity to do so.  This means involving  the patient increasingly in doing it with the social worker,  in moti÷ vating  him  to  do it for the social worker and gradually in doing  the  coping work for himself. This is the pedagogic level!
2.  Understanding the role,  importance,  and scenic stage-meaning  the entire living-group  of the flat plays for the patient.  To what degree does  he revive,  put  on stage his infantile traumatic primary group and what  aspects of it  are  being revitalized in a frenzied effort to cope with living in  the  shel÷ tered flat.
3. To clarify, what the institution does mean for the patient. In our experi÷ ence,  the transference  on the institution can give us much insight  into  the primitive defense  mechanisms  of the patient and how he  experiences the world at large.
4. To understand the direct interpersonal transference of the patient onto the  social worker.  This  is frequently very intensive and  often gains  para÷ mount  importance for the patient and necessitates the capacity to be able to work with transference, counter-transference, and resistance.
5.  The social  worker  almost always  has  to take  over  motherly and fatherly  functions  in order to be able to support the patient effectively in  his personality  growth. Frequently we have to cope with such a high degree  of deprivation that the living group and its conductors will obtain the importance of a  secondary family experience for the patient and  milieu-work  becomes necessary.
6.  His most important role, however,  seems to be to support the patient to acknowledge that he has deep rooted,  unresolved psychological conflicts and,  or, deficiencies in his own personality structure, and, above all,  that he himself  is the origin and source for a change to improvement.  To make suf÷ fering  ego-alien, to  support him in his quest for growth and to confront  him with  the fact  that  his plight is not only a result of  miserable  past circum÷ stances or of a genetic defect, but can be influenced by him, is the foremost task in motivating the patient.
Frequently,  they where  vaccinated by other psychiatric authorities  with the  "information"  they would have to undergo psychopharmacological treat÷ ment for the rest of their life, and would have to visit their psychiatrist's office every 2  to  3 weeks to receive their.  This dependency  that  is fostered  is frequently  guarded with  great jealousy and petrifies the  patient's  arrested symbiosis  with his live forbidding primary group.  The mere consideration of psychotherapy  as an alternative way of treatment is sometimes  considered as a conspicuous signal for another impending psychotic reaction.
7.  The development of a vision.  The social worker's role is,  to open up new  frontiers of  human  existence for the patient and to  make available  a personality growth project for him,  in place of life-long stagnation,  or even a fading  away of personality.  It involves imagining and developing a future for the  patient  in order to be able to accompany him on his way.  Many  of  our patients  were denied a vision of their future and not few where locked into a dead end street.  This process of imagining a vision of a future involves not only  the social worker but the entire living-group of the sheltered-flat and  at times the large group.
In face of all these demands the social worker must become aware, that he is not the patient's psychotherapist and that it would be futile to enter into a rivalry who is the better psychotherapist.
The Transference on The Institution and its Meaning
The umbrella organization, that supports the sheltered flats and sustains the  physical and  even  more their  group-dynamical  existence is  of  high importance  to  the patients in a very direct way.  The institution mobilizes  in my  experience very  archaic feelings and can not be dismissed  as  only of minor  psychic  importance. Because  the institution is  seen as  somebody, who has the power to structure their life there can,  at times,  exists profound trust into the perceptions the institution offers. The institution and their repre÷ sentatives become objects of transferences,  the aim of the most ambivalent feelings. It  provides  security but  also becomes the  source of  feelings  of being completely controlled  or even devoured.
Especially  in order  to  cope with this level,  there  takes place  once  a month a  large  group, where the inhabitants of all three existing  sheltered flats  participate in,  as well as the social workers and members of the  board of government of the umbrella institution.
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 embracing the different flats and creating the feeling of one large community.
The  large group is the place,  where the feeling of living-culture can  be felt best, because the different groups can perceive each other, become per÷ ceived  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 supportive backbone,  which gives strength  to critical  members and does help to make hidden conflicts visible.  It strength÷ ens  the institutions  group-identity  and helps  to  provide new  strength  to encounter the outside as well as the inside
Psychotherapy and How Does it Start
Our aim is to motivate the patients to participate in psychotherapy, group or individual,  if possible at least twice a week.  This is because we know we can not,  within a limited amount of time and with limited manpower,  provide a  continuous and deep reaching,  restructuring psychotherapy.  But,  above all, a highly diversified setting offers ample opportunities for splitting and var÷ ious possibilities to transference.
However, we do carry out some pre-psychotherapy. It works on the outer level of personality and besides having to overcome an obstructive anti-psy÷ chotherapeutic  ideology,  mentioned above,  it has to foster a need for help, for  introspection and simultaneously has to support the severely  narcissisti÷ cally  injured  patient to become able to face his real plight in  all its  dimen÷ sions.  Only by doing so, grows the possibility that formal psychotherapy and the long-lasting  relationship  necessary to do it may become  tolerable and might become sought after.
To  experience  psychopathology  as pathological  is  a highly  violating experience.  The more  ill our patients are the less are they able  to  tolerate this "narcissistic  injuries"  and it  is our experience that it  takes up  to  two years until  they  become interested in experiencing their  pathology and  in getting rid of it.
It  is our  firm conviction that psychotherapy should have a place  in  the development  of any of our patients.  This is one criteria that differentiates  a stagnation flat from a human growth provocative flat.
The Role of Supervision
Because  the patients tend to put on stage and revive their  infantile,  pri÷ mary groupdynamics,  it is a matter of course, that the social worker will be a prime object of enmeshment,  entanglement, and transference.  To a certain degree  it  is also necessary to fetch the patient, where he stays now  in  his psychic capacity.  Thus  it might be even necessary that the social  worker takes  over mothering or fathering functions at a certain point.  However  the patient's striving  will  frequently be  to produce  a transference  that  lures, coerces  or seduces the social worker into that role and position that  is  the least  threatening for the patient and tends to petrify the status  quo,  respec÷ tively  continuing stagnation.  Supervision thus becomes necessary on three levels:
To  help the  therapeutic  community worker to find himself  and to  stay with  himself amidst the interpersonal and group-dynamical forces of  enme÷ shment he is exposed to.  To become able to bear feelings of  countertrans÷ ference, without submitting to the feeling of becoming the patient's puppet or revolting against this feeling by acting out.
To help to clarify how exactly the individual patient is reproducing his pri÷ mary  group-dynamics  or aspects of it within the group-matrix of  the  shel÷ tered flat,  and what particular roles,  respectively personality-parts he attrib÷ utes to the various others.,
To  help to  reflect conflicts within the team  as a  counter-transference- reaction to splitting and fragmentation, going on within the group of patients.
Final Comment
What  about the mass of revolving door patients?  Can we provide a per÷ spective  for  them. The therapeutic community within the community  offers one very unique space to experience ego-deficiencies,  and simultaneously give a chance to experience and internalize a constructive and ego-develop÷ ment furthering  experience.   It  makes  it possible  to  cope with  primitive defense  mechanisms in a very complex,  yet integrative  way.  This setting gives  a chance to act out,  yet works continuously on  group-boundaries,  to prevent the destructive parts to become victorious. It gives a constant reality challenge,  such stemming against malign regression as well as against the dissolution of personality, so frequently described in the orthodox psychiatric settings  that can  end  at its worst in hospitalization.  It gives  a  chance to experience a sibling group with ..... foster parents that strive to  reenforce  the constructive  group-dynamics  and  to struggle against  the  destructive one. Yet at the same time a chance is given to put into scene the original destruc÷ tive  primary  family group  experience that has  become personality  in  the meantime. The setting's unique chance, as we can study it so far, is to open up  patients for  psychotherapy that so far have never  thought  of it,  where never  supported in seeking it,  and above all,  never could feel the need and desire  to take  part in it.  It gives patients a chance to enrich their  lifes that previously  were  endangered to slip into chronic abuse of  psychochemicals and into the gradual regression of their personality.
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