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.
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.
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.