- 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. Introduction
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.
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- apy. 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. Furthermore, 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 outside. 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- ber. 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- ties. 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 them. 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 case. 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 problems. 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 destroyed. 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- tion-formation. 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