time limited therapeutic community - Andreas SG.vo Wallenberg Pachaly

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

Title
Direkt zum Seiteninhalt
Ebene 10
The time-limited
Psychoanalytic Milieutherapeutic Community
Andreas von Wallenberg Pachaly, Düsseldorf (FRG)
The Free,
non governmental, non profit
Counselling Center in Psychotherapy
ABSTRACT:    An outline is given of the setting, theoreti÷ cal and conceptual background, and the therapeutic capaci÷ ty of the time-limited therapeutic community working along psychoanalytic and ego-structural lines.  Certain key ele÷ ments of the time-limited psychoanalytic milieutherapeutic community (PMC) are discussed in detail e.g.: daily struc÷ ture, project-work,  the  children's group,  roomsharing, structured versus unstructured time, staff requirement for the  PMC,  indication and counterindication for participa÷ tion  in a PMC,  the integration of the PMC into a global, comprehensive,  holistic treatment setting, etc.. An out÷ look  is given on the future possibilities for PMC's  and open questions are raised.
Introduction
The time-limited Psychoanalytic Milieutherapeutic Communi÷ ty  (PMC) is the attempt to create a highly differentiated group-environment   that   serves   as    a   facilitating environment  on  the one side and simultaneously  provides the  chance to confront destructive personality parts  and to  separate from an internalized destroying family dynam÷ ic.
Originally we conceived the PMC for patients that have se÷ vere difficulties to express verbally their feelings,  but who are  still able,  though some only with  considerable support,  to undergo outpatient-therapy. It was our ratio÷ nale  that  by doing activities together it would be  much easier to come into contact with these patients and even÷ tually  even become possible to communicate about feelings and  to foster insight.  This means in orthodox diagnostic terms,  we chose severe borderline patients, manic-depres÷ sive reacting patients, and schizophrenically reacting pa÷ tients, which had no acute reaction.
In the course of the years, however, we have learned that all patients with significant developmental deficits as a result of deprivation, denial of a caring and a facilitat÷ ing  environment, profit from the PMC. Patients with the prevailing defense mechanisms of splitting and intellectu÷ alization  and  psychosomatically reacting  patients, can gain  significant advantage from the stimulating and chal÷ lenging milieu of the PMC.  Also the typical cancer-perso÷ nality  with his deeply internalized prohibition to  live, his  deep  resignation,  his lacking capacity  to express feelings, and to assert himself as has been previously de÷ scribed by Bahnson (76),  Leshan (66), and others can take considerable advantage for their personality development. Parents, taking along their children seem always to mature considerably  through the PMC experience,  because it com÷ pliments  the more or less isolated modern nuclear  family in a very enriching way and makes possible the development of  new  dimensions within the parent child  relationship. The greater diagnostic range of the participating patients of  our  PMC's today has proven valuable to  all partici÷ pants, because the specific sensitivities certain patients bring into the community become also available to the oth÷ ers and the PMC in its entirety as a diagnostic and thera÷ peutic tool becomes more differentiated.
In  my understanding the PMC is only one,  though very im÷ portant  part  in a differentiated net of  treatment set÷ tings. It is necessary to establish an individually struc÷ tured  treatment setting for every patient,  being  either more analytically  questioning and confronting,  or  more nurturing and supporting in order to enable the resolution of  internal  conflicts and the retrieval of  a deficient personality development.  An integrated setting of  shel÷ tered  flats, where severely instable patients can live, out-patient  analytic group-therapy,  combined  individual therapy, and the participation in PMC's represent a power÷ ful variety of therapeutical settings and for the individ÷ ual  patient forms a therapeutical net that has to be  in÷ terrupted even in the case of severe crisis only for short periods of time by hospitalization.
This setting offers possibilities beyond the group-analyt÷ ic therapy and yet avoids the pitfalls of in-patient ther÷ apy with its potential for malign regression.
The theoretical concepts at work
The theoretical roots of the PMC are manifold: The psycho÷ analytical  one of Freud (1924) and Simmel  (1929,  1936), the groupanalytic one of Jerome Frank, Horrowitz et al., the ego-structural of Ferenci (1921) and Ammon (1959, 79), the  British TC movement of Maxwell Jones  (1953),  Thomas Clark (1964),  Tom Main (1989),  and Stuart Whitely (1979) with the challenge of democratization. And since the early 80ies the struggle to integrate a social-psychological ap÷ proach,  where I am influenced by my Japanese teachers Hi÷ toshi Aiba (1977).
However,  the  PMC is a highly differentiated field with a complex matrix of supporting, challenging, and confronting dimensions,  whose  rationals are complex and need further exploration. Here I discuss only one factors and leave the differentiated  discussion of the others to further publi÷ cations.
The PMC as a comprehensive, integral diagnostic, process- diagnostic tool (Wallenberg,  1980), which leads to direct consequences.  By  providing the complex network of groups and  subgroups,  the patient is able to project,  identify projectively, split, deny etc., all other forms of defense mechanisms as well as act out character defenses in a very direct way in the community.
It  is my understanding that personality structure can  be understood in terms of internalized group-dynamics, which however  can be petrified and thus become unconscious to a degree so that only very isolated symptoms so to say sur÷ face.  The rest of the pathological psycho- and group-dy÷ namic  is acted out in a dream-walkers way without  ever reaching  the patient's nor in most cases his present  li÷ ving-group members' consciousness. The PMC, by integrating this acted out part of the pathology - so to say the other 10/11th of the iceberg,  and by having developed itself to a  very sensitive organ to sense unconscious  relations, hidden  meanings,  and complementary behavior of the other group-members, ruled by countertransference, can develop a new understanding of the patient, his actions, and his mo÷ tivating forces and encounter the patient with more  dis÷ tance and yet much more empathy from this new understand÷ ing.   This   can   make   possible a   more   meaningful communication with the patient on his behavior and his in÷ ner world.
Another important theoretical dimension of the PMC is that interpretation  are  not only being given verbally to  the patient,   but  interpretations can be acted by  behaving, interacting, doing, and not doing. This can be a much more powerful therapeutical instrument than the verbal inter÷ pretations  with  patients, for whom speech never  really gained any significance.  To handle this instrument of in÷ teractive interpretations, as I have called it, the aware÷ ness  and the handling of one's feelings of  countertrans÷ ference  caused by  a  specific patient  or  a specific situation of the group is of paramount importance for the therapeutic success of the PMC.
Setting up the Community
These  PMC have been carried out for now over 17 years  by myself, in cooperation with other group-analysts, with ad÷ vanced  students of group-analysis,  and recently also  by students of mine.
The  PMC's  have taken place over the years at the  same place,  an old  farm  house and since five years  an  old manor. This continuity seems very important, since only by this some attachment can grow, the material culture can be incorporated by the PMC,  and a therapeutical heritage can come into existence.
The  PMC  lasts usually 17 days with a variation  from 10 days  to  four weeks and are usually carried out  twice a year.
The  PMC  starts in the heads and hearts of the  staff, a group  of  three to five group-analysts doing  out-patient therapy.  They work closely together in a weekly supervi÷ sion group and lead 5 to 10 (both figures have been chang÷ ing  over  the years) out-patient groups with 8 to 12  pa÷ tients  each. They also conduct individual therapies and psychoanalysis.  To  this group do also belong students of group-analysis.
The  diagnosis of the patients treated range from neurotic to borderline, narcissistic personality disorder, perver÷ sion,  severe depression,  psychosomatically reacting pa÷ tients,  to  schizophrenically and psychotically  reacting patients.  The group of  therapists shares its phantasies concerning another PMC, decides, who will lead it,  start the  discussion,  for which particular patient there might exist  an indication at this time in his therapy,  on  ac÷ count of his diagnosis,  present psychopathology and  his present  groupdynamical living circumstances.  The group- analyst brings this discussion into the respective therapy groups.  The feasibility, pros and contras,  regarding the participation  of any particular patient is worked through by the entire group. After the PMC the patient will return into  his therapy group.  There exists also the possibili÷ ties  for patients in individual therapy to participate in the PMC if there is an indication.
At  least  six weeks before the actual start of the PMC  a group of 15 to 18 patients that will come along is  defi÷ nitely elected.
The patients that work, are in some kind of educational or training  program, or have some other kind of  engagement have  either the possibility to take vacation for the time of the PMC or they can themselves let declared as "ill" by a  general  practitioner (MD) on account of their  illness and because  they will take part in therapy and thus  can stay  away from work without any negative  consequences. Usually  every  patient decides this for  himselve  after working through the meaning of the respective possibility in his therapeutic ongoing setting
The funding is done by every patient himself,  where again it  will be the task of the patientPMCs therapy group  to support him to find possibilities.  The costs,  including bed and board and therapy are ca. DM 80.- a day.
There  is no possibilities to fund this therapy within the official health system, however our experience is that opn the  one  side to fund this therapy by oneself gives it  a special meaning and on the other side we try to keep costs as low as possible, so that even economically poor patient are able to participate in an adeaquate number.
The  group now meets three to ten times before it  travels to  the place, where the community will take place.  The task  of these sessions are groupdynamical ones,  to work through expectations, overwhelming anxieties, but also to arouse curiosity and to let the group come into existence. Besides this,  organizational matters too are  cared  for and the  group starts to take over  autonomously  certain functions.
The patients that take along their children meet in an ex÷ tra  session with their children and the educators of  the children's group.  Thus the feeling of a growing group ma÷ trix can come into existence.
Finally, the group travels in small groups from their home city to the location of the PMC and the first day is spent in  cleaning up and making comfortable the rooms and the whole place.
On the first day a tour through the building and the area around it is given and its history is narrated.
The  meals are prepared by three members of the  patients' group  and after  dinner the first analytic  group  takes place.
All patients and the staff stay during the entire communi÷ ty at the location.  Each of the staff has a private room. Two  patients  usually share one room.  The patients  are asked  not to leave the area without prior discussion with the group.
Basic elements of the PMC
as they have evolved over the past two decades.
The daily structure
The day starts for all at eight o'clock with breakfast.  A group of three patients is responsible for preparing  the breakfast,  waking up the fellow patients,  and preparing fire in the large fireplace of the breakfast-room.
From  9:15  until 13:00  is  the first  block  of group interaction.  Usually  this is project-work.  At 1:00 p.m. there  is a large lunch.  Since the same crew of three pa÷ tients,  who  is preparing  lunch also is responsible  for shopping it  means they must be capable of  managing  the time. Otherwise the whole group won't be able to eat until whatever time.
After lunch until 3:00 is unstructured time. From 3:00 un÷ til 5:00 there is either a short excursion, swimming in a hot  spring near by,  a sport game for everybody (patients and staff), going for a walk through the rain-forest near÷ by,  or  on some days project-work including shopping for some projects.
From  5:00  to 6:40 is the daily  group-analytic  session. This is the central integrating psychological and  group- dynamical  space of the day.  7:30 to 8:30 is  dinner. At 21:15  until  23:00 is either seminar,  psychodrama or  on some days a bonfire including barbecue.
Project-Work
One  central  element of the PMC is the carrying out  of meaningful,  serious and respectable work-projects.  For this  purpose the  group is divided  into three  project groups of 5 to 6 patients.  Each group elects its own pro÷ ject-leader.
The  project each group will have to accomplish during the PMC (like  building a swing,  a veranda, or a  sheltered place  to carry out groups) stands in relationship to  the community's  live (like a large table for dinner) and  de÷ mands real craftsmanship.  That means it is not  "occupa÷ tional  therapy" to keep the patients busy,  and only  of as-if  value, but  has  a genuine value  for the  entire community.
The group organizes its work by itself. The project leader is  in charge of the "project management",  of the time- table, of keeping group-cohesion sufficiently high, of ne÷ gotiating who does what, and of the over-all responsibili÷ ty that the project is accomplished. It is a truly respon÷ sible position.  Of  course, he  doesn't  have to  know anything  but can get help from whom he wants.  Also from professionals outside the community.  So he has to develop the  capacity to be able to fetch for help.  But he  also must be able to coordinate and lead the project group in a groupdynamical way. Of course, the leader can fail and the group  has the freedom to vote him out of office by elect÷ ing  another  member of the group.  At some occasion  the group  will also  apply for a member of  another project group as its leader.
The function of this project groups is a multiple one.
-   It is a space that is being opened up,  where a "third object" (Winnicott, 1972) is being introduced, which gives many patients new ways to communicate,
-   it is a field,  where the constructive,  healthy ego- functions, the creative parts of the personality-structure can come alive,
- a field,  where the destructive parts of the personality can  be acted out into the therapeutic field,  because  of course the  realization of the project is not a one  way- street  without flops,  failures and disappointments,  but the genuineness of the projects gives the human processes involved a sincere character.
-  a field,  where advanced patients can try to take  over responsibilities  as project leaders,  where they can test their  capacity to keep groups together,  to motivate oth÷ ers,  and to take into consideration individual capacities and deficiencies.
It is part of the grown culture of the project groups that all  members are allowed and supported to do everything, e.g.  patients, who never successfully handled a drilling- machine are supported to do so.  It is the way the work is accomplished, which is valued as much as the product.
The  task  of the therapist in these project-groups  is  a multiple  one.  It ranges from support to confrontation. This  means supporting individual patients at work,  con÷ fronting  them with destructive or antisocial  tendencies. Supporting the project leader in his leadership,  but also the  group-members in their negotiations with the  leader. At times, for instance, the leader will be confronted with his autistic or authoritarian way of leading the group in order  to enable  a group-process that is different  from the past and not merely a repetition of destructive forces having been at work in the patient's primary group.
Last not least the project group gains for many patient an important  function of demarcation against the  frequently as  threatening experienced large group of the entire com÷ munity.  This  security providing function is  especially strong in the early phase of the community.
The Seminar
This is the intellectual project of the community. The aim is  to challenge the patients intellectual capacities  and to  confront learning or reading difficulties as well as the difficulty to speak in front of groups.
Two or three patients together will make a presentation of books,  scientific papers,  review of literature mostly on topics of psychotherapy at large, of history, or of social and  political concern.  The presenters had at least  two weeks  time to prepare their work and to discuss the  sub÷ ject  together. After  the presentation the entire  group will enter into discussion with the presenters.
The  aim is to open up a groupdynamical space,  where  the patient on  very different levels can put into scene  his conflicts,  but also,  where  his deficient personality- structures  can be  perceived,  understood, mourned,  and where  the process of a retrieval of ego-functions and the restructuring  of personality-structures can be initiated. The seminar is another place,  where patients can put  on stage the groupdynamics of their conflict, e.g. refusal to learn,  to identify with teachers, deep rooted feelings of inferiority  on  an academic level,  deficient conceptual thinking capacities  etc..  The different topics and  the manifold approaches taken by  fellow patients towards this intellectual project represent a significant challenge. Of course this is a process, which is only triggered at best by the actual seminar and will have to be followed up and worked through in the following days and weeks.
The  seminar becomes for many patients of great importance in  order to become able to perceive themselves as a  his÷ torical  being,  existing with a meaningful past and  with perspectives  for  a meaningful future,  also in order  to sense their capacity not only to be a passive lump of his÷ tory  but to gestalt one's lifestyle.  On a broader social level   the   capacity for  social  concern and   social participation (v.Wallenberg, 85) as well as the search for one's own stance in society, too, are significant elements to be pursued in this context.
The Children's Group
There  exists the possibility for our patients, to  take along their children. This is a unique feature of our PMC. It enables  parents to integrate the  mother/father-child relationship into the therapeutic setting.  This is of di÷ agnostic,  therapeutic,  and pedagogic value.  The parent- child  relationship becomes visible and observable in many aspects,  e.g.:  at meal-time, the bringing-to-bed situa÷ tion, the  parent-child separation,  when the children go into their children's group, which is headed by two educa÷ tors. The  children's capacity to relate to other  adults and  to other children is observed and can be put into re÷ lationship  with the parents attitudes towards their chil÷ dren.
At several occasions an interchange group for the parents, the educators,  and the therapists takes place and impres÷ sions,   observations,  attitudes, and  informations  are shared and an attempt to integrate them is made.
For  the children themselves the group can become of  con÷ siderable  importance in the relationship with their  par÷ ents. It can provide a holding function and a counterbal÷ ance  to the influence the parent exerts on  him. Usually children grow more self-confident,  feel stronger in their relationship with the parents,  and acquire more self-con÷ fidence. But quite frequently the group perceives also as÷ pects  in  the child,  the parents have not seen  so far: constructive possibilities,  the  capacity for caring  or leading, but  sometimes even severe  handicaps, language difficulties,  or  disturbances, the parents have "scoto÷ mized" up to now.
The  presence of the children is also a strong  confronta÷ tion  for the non-parent fellow-patients with their  own childhood,   with their infantile longings,  and last not least with their own attitude towards becoming a mother or a  father themselves.  This is also supported by the  fact that fellow-patients,  at one time or another,  take over parenting functions in place of the real parents.
Excursions
Once a week during the PMC an all-day lasting excursion is carried out.  This  has various meanings:  The group and their  members are challenged to enjoy a whole day outside the "walls"  of the PMC and to enter into specific encoun÷ ters, like an exhibition of van Gogh, or sailing, they are confronted  with  certain aspects of society and  history, e.g. by  the  visit of a war museum with the German  Nazi past. The large group as a constructive, holding element, not as a regressive one is challenged by this.
During  excursion day the patients are left to their  own, have to structure their relations during the day. It is up to them to make contact with people outside the community. In  general these excursions are experienced very exhaust÷ ing. This is less because of the mere physical exhaustion, but  because the patients have left their familiar  field. The  patients leave the field of social energy inside  the PMC and move around in a loose net of relations, where it is  up  to them to take  the  initiative. This,  besides intellectual  or physical stimulation is the actual  chal÷ lenge of  the excursion and helps to understand  the  pa÷ tients better.
Why shares Who with Whom his room
It  is  our clinical understanding that not only the  pa÷ tient's  relationship to staff members or to the community as  a whole is of therapeutic significance,  but the rela÷ tionship  with  certain fellow patients too can stand  for possible significant  encounters.  This can range from  a collusion in psychopathology, to vast indifference, on the one side,  and genuine interest or even character confron÷ tation on the other side.  By character confrontation  we mean the phenomenon that the mere style of existence,  the encounter of personality structures for instance represent to  each other split off parts of the personality.  Within the  intimacy of the shared room,  this can trigger inter÷ personal  and group-dynamical processes that will be  of value  to  the entire therapeutic process opposite to the effects of pathological collusion.
We  thus propose  specific room arrangements to  the  pa÷ tients, trying to take into consideration on the one side the feasibility, wether the patient will feel at ease with his or her room mate,  and on the other side,  a large en÷ ough capacity of the ego-function of ego-demarcation with÷ in the overall personality structure, to counteract collu÷ sion and to enable a caring attitude towards others.
Usually  the staff's proposal for the room-sharing is  ac÷ cepted  or leads  at  least to  an  intensive encounter regarding  the  underlying observations that lead to  this proposal.  Over the years, however,  a culture has evolved and  a considerable degree of curiosity usually is present to enter into this kind of room sharing.
The daily analytic group
This  is the central integrating space.  All patients par÷ ticipate  in this group,  which is conducted by the senior therapist and the co-therapist. At the same time the chil÷ dren have a play-group of their own, conducted by two edu÷ cators. So their parents-patients can completely feel free to participate wholeheartedly. Thus the phenomenon of par÷ allel  group-processes frequently can be observed and fur÷ ther the understanding of the ongoing group-processes.  To facilitate this  every  evening the staff meets  and ex÷ changes feelings, observations, interpretations, but also clarifies his own interrelations.
The  daily analytic group the group tries to work out  an understanding of how each patient's position in the group, his behavior,  his ways of relating to other, etc. relates to his primary group-dynamics,  and to what extend he  is governed in the here and now by repetition compulsion.
This  putting on stage of the primary group-dynamics,  un÷ consciously  yet compulsively,  is one of the miracles and huge chances of the PMC.  By this,  the continuously life- damaging structures and unconscious motivations of the pa÷ tient can be observed,  reflected upon,  reacted to,  ac÷ cepted as  originally meaningful for the patient's  life, and finally be interpreted. Simultaneously the patient can learn  and above all experience that he is not dependent upon  his  family for survival,  but that other  important humans accept him the way he is. This atmosphere of toler÷ ance  and acceptance going along with the distinct percep÷ tion of the obsessive compulsive pattern in his life-style makes possible separation from old structures.
We frequently observe that patients almost instantaneously establish their infantile group-dynamical position within the  PMC and experience the group the way they experienced home. This experience can be so powerful that it takes the energy  of the entire group to help the patient to  demar÷ cate himself from this experience.
This can be done not only by accepting the patient the way he is, yet confronting him with the perception of the oth÷ er  patients but,  at least equally important,  by giving space  to the healthy personality parts of the patient and creating a situation, where he can experience genuine rec÷ ognition.
Only  this will give him the feeling of security,  so that he will be able to "tolerate"  deficiencies in his person÷ ality  and  not rigidly rely on the defense  mechanism of projection,  idealization, splitting, or denial.  Feelings of  desperation and loneliness can be admitted and shared. The  self-immunizing attitude can be left behind and  only now personality growth becomes possible.
This is especially true in the case of severe narcissistic personality disorders that originally reject any percep÷ tion of the world that differs from their own,  experience it as threatening on the one side and arousing overwhelm÷ ing  feelings of guilt on the other side.  Because the pa÷ tient  experiences the differing perception as a condemna÷ tion,  disapproving of his/her personality,  he objects to this  treatment and thus becomes unable to experience  the encounter as something interesting and valuable.
In  the case of borderline patients the integrating forces of the PMC are of paramount significance. This I will dis÷ cuss in more detail in another paper.
The Seven Phases of The PMC
The group-dynamical process of the PMC in my understanding can be divided into seven phases.
1.  The conceiving phase: This is the time where the staff deliberates the feasibility of another PMC. The exact time it will take place and the duration is scheduled,  the ap÷ proximate number of patients that will be able to partici÷ pate  is determined,  the staff responsible for the PMC is selected, possible  working-projects are  discussed,  and above all criteria for the selection of patients are dis÷ cussed,  the patients are approached and the possibilities of  their participation as well as financial problems  are discussed.  The pros and contras are worked out within the framework of their ongoing group-therapy.
2.  The preparation period: This is the time where the pa÷ tients start meeting weekly in a new group, still in their home  town.  The patients learn to know each  other, they share  expectations,  fears and anxieties,  they start to cope with the large group-experience, they tackle reality problems, form  sub-groups that are in charge of  certain tasks,  it is  worked out who shares with whom  the bed- room,  the project groups are constituted,  the plan,  who cooks with whom  is established, etc.
3.  The phase of arrival:  This means all patients have to arrive not only physically,  but also in an emotional way. They  have to separate from home,  from important persons, and they have to dare to make the step into the group,  to disclose themselves, to take up confidence into their fel÷ low  patients,  to the group as a whole,  and to the staff members.
4.  The middle phase:  The middle phase is the time,  when the patient's central conflict and/or deficient dynamic is acted in into the PMC.  The patient has the possibility to experiment,  to experience his positive ego-functions,  to share skills,  interests, hopes,  anxieties,  phantasies, memories,  traumas, etc. with the community and to experi÷ ence  the group and its members differently from the world of his inner objects, from important persons of his previ÷ ous life or partial aspects of them.
He doesn't feel so alone any more, consequently he can al÷ low himself to feel all the feelings he had been  fending off all the time.  This means not more and not less than a process  of activating the violations he had been  suffer÷ ing,  to recognize their reality, and to enter into a pro÷ cess of mourning over the lost childhood. Because the fix÷ ation on the violating experience frequently had prevented the  patient from making new experiences,  they also  had prevented  him from entering into a learning process  that ranges  from learning for  love to love for learning (Eck÷ stein et al. 69).
The middle phase is the time, when the live preserving and the life-forbidding forces wage and when the patient  has to decide on which side he wants to stand on.  This is the time decide anew or even for the first time for or against life.
5. Separation from the community: As a rule, at the end of two thirds  of  the PMC's duration the  entire community makes an all-day lasting excursion.  This means on the one side  a high-light of the entire stay,  on the other side the start of the separation-phase. The end of the communi÷ ty  comes vividly into consciousness.  The group-analytic session  on the evening after the excursion is on the  one side influenced by the day's experiences, but also by the forthcoming termination of the community's existence. This separation  phase during the PMC frequently gives patients a  chance  to communicate feelings and experiences  that touch  deep lying experiences of abandonment,  separation, loss and expulsion.  Of course, for some patients the end of the PMC means also relieve from the presence of a group that  is being experienced as threatening.  It is in  this phase  that the working through of the defense of feelings of separation and abandonment by undoing, denial, and oth÷ er  mechanisms becomes a focal point of concern.  The good group-experiences,  can they be incorporated, or must they be dispelled of.
6. The post-community separating phase: The two months af÷ ter the PMC are characterized by saying good by to fellow patients  in the course of several follow-up sessions,  of trying to convey the own experience and its importance for one's personality development to one's fellow patients in the long-term group-analytic group back home. To strive to live the achieved changes in attitudes, insights, behavior within one's regular daily environment is a further  con÷ cern. Last not least the tendency to deny, to undo every÷ thing  occurs and becomes an object of continuous analytic concern.
7.  The phase of integration.  This phase may last as long as  one year or even longer,  because specific encounters, experiences,  feelings,  ego-states that where encountered throughout  the  PMC may suddenly pop up and become  the bases  for a new, very profound working through of a deep lying  conflict or the confrontation with a deficient or destructive  part  of one's personality.  The experiences during  the  PMC give an emotionally more secure  base  to dare to go beyond one's habitual defensive posture.
It is my experience that this integrating phase under suc÷ cessful conditions fades into a phase where the PMC  will have become  a part of home,  especially in the  case of originally  severely ill patients.  It will have become an emotional  stabilizing basis on the one side and part of a vision to gestalt one's own life on the other side.
Case Study
I remember here a patient who the first days of the commu÷ nity behaved very enthused,  rather hypomanic. She, howev÷ er, complained increasingly that her 10 year old daughter, who was with her,  missed her father, felt not accepted in the  children  group and wanted to go  home. After  three forth of the stay she packed her bags late night, tore her daughter, who obviously for everybody had become very fond of  her children's group,  out of bed and wanted to leave. During a one hour lasting final talk with the senior ther÷ apist she revealed that she felt like being at home,  psy÷ chologically, almost physically tortured, she felt like in a concentration camp.  Meanwhile,  many of the group cared very  warmly for the daughter,  made her  hot chocolate, comforted  her,  and just set around her and gave her  the feeling she was being held.
The  mother finally revealed that her father had forbidden any  contact whatsoever to outsiders for over 15 years and the  more  she felt comfortable here the more she felt  an unbearable anxiety rising, she grew increasingly afraid to turn mad.  Her  own mother had died at the age  of three months  and  she felt for the first time all  the hatred, over  having been abandoned so early.  Quite obviously she hated  the mother group for this and yet was afraid to ac÷ cept  the warm holding group for fear of being left  alone again.  Another  dimension popped up by being  confronted with  her parenthood through the fellow parent-patients. She  had never experienced a mother of her own and so she wanted very much to be a good mother.  However, she really felt  ex- tremely incompetent,  unsure of herself and  was afraid of loosing her daughter or ruining her.
This  patient exemplifies the possibility of externalizing an  entire group dynamic into the matrix of the PMC.  I do not  want to detail here all the different fellow patients and group-setting  with their respective meaning for  the patient.  But what is demonstrated is that the PMC can be÷ come a diagnostic field by understanding the acting-out of the  patient and how she makes use of it by  projection, projective identification,  splitting,  denying, etc. But also the existential importance of the PMC becomes obvious as a healthy, life supporting, holding mother-parent  that eventually enabled this patient to continue her therapy in the PMC.
Structured versus unstructured Time
One  interesting aspect of the PMC is how time is  dealt with. On the one side there is much time structured, which has several functions: It offers security to patients, who have great difficulties to structure their life,  it alle÷ viates feelings of guilt and helps patients, who are driv÷ en by irrational feelings of haste,  and it gives an exam÷ ple for identification, how time can be coped with.
The  unstructured, so called spare time too has different functions.  There may be the escape from challenges in in÷ terpersonal encounters, challenges in work or intellectual capacities,  but there is also the capacity to enjoy one÷ self,  enjoy non-structured encounters and to discover the world, to pursue one's interests and to enter into new en÷ counters.
Another  interesting aspect is the fact that the more  the differentiation of the community progresses,  the more the group  develops a feeling for its own rhythm and  develops its own time. That means that the daily rhythm adjust more to  the community's needs and less to the dictatorship of the clock.
The question of combined individual therapy
It  is our experience that regular individual sessions are neither  necessary nor do they further the group  process. However in specific cases,  if the group is either experi÷ enced by the patient as too threatening,  or if it is nec÷ essary  to support a patient in his demarcation  against fantasies,  feelings, etc.  that threaten to overwhelm the patient  to an  extreme  degree,   additional  individual sessions may be of importance.
Frequently, too, individual patients form very close rela÷ tions  to fellow patients.  This of course demands a  con÷ stant  flow of communication,  and an effort to  integrate the significance of this relationship into the community. The  same is true for intensive individual encounters with staff-members during the course of a PMC's day.
Staff requirement for the PMC
The difficulty for the therapist lies within the permanent oscillating process  between joining the patient  in  his daily live, eating together, working with him on projects, to accompany and confront him on a very direct,  personal, and real  level.  Then withdrawing,  to open up a space, where  the individual patient as well as the group have  a chance  to reflect the relationship that has evolved  with the  therapist, which of course is mingled with all kinds of transferences.  On the other side the therapist is also experienced  as  a real human being and stands  under the spot-light,  with all his positive and negative qualities. If he  prefers to dive away in his ordinary life and  has made a life-style out of the analytic neutrality, he prob÷ ably will  drown pretty soon.  He is directly  confronted with  his own way of experiencing groups.  Does he experi÷ ence them as threatening,  devouring,  or even persecuting or  as a secure environment,  where he feels protected and can develop interests for his fellow beings.
Does the PMC harm anybody
Highly  narcissistic personalities are frequently so  much threatened  by other's perceptions of themselves and the world  around  them that they prefer to stay away  from  a group  experience  of this intensity.  They might be con÷ fronted  with  the emptiness behind their facade and  with their feelings  of abandonment to such an  overwhelmingly high degree  that they might need even combined individual therapy during their ongoing group-analytic therapy.
The personality with highly denied, strong symbiotic needs may be  flushed by the PMC experience and not be able  to tolerate  the  strong feelings of psychic pain  separation from  the community evokes.  Thus it is the  time-limited character,  which seems  to be contra-indicated for  this kind of patients.   However, because of the fact that the PMC is a strong diagnostic instrument (Wallenberg,  79) it may  not have been possible to recognize the intensity  of the symbiotic complex before, but only within the field of the PMC.  And on the other side it is exactly the time-li÷ mited  quality which counteracts malign  regression,  fre÷ quently observed in an in-patient setting with severe bor÷ derline patients.  So  here  the difficulty is  to  steer between syllabi and scarabs.  Combined individual therapy following the PMC can be helpful.
Generally  we can state that from our past 17 years of ex÷ perience  with approximately 225 different adult  patients participating  in  PMC's we had only  one  hospitalization during the stay,  we had no break offs and we had only one more  serious accident,  (a simple bone fracture by a  pa÷ tient falling from a chair she had climbed to fix a bulb). About  50% of the patients have participated in more  than one PMC.
Over  the years we had increasingly less break offs in the post  PMC period (three months),  diminishing to less then five percent.  We have more than 70% of patients that par÷ ticipate  at least in two or more PMC's at a rate of 1 ev÷ ery one to two years.
As  an overall rating of the therapists leading the on-go÷ ing analytic groups, we can state that 75% of the patients participating the first time profit considerably and about 90% participating two or more times profit considerable in terms of  stability,   awareness, insight,   personality growth. The remaining 10 percent represent the therapeutic challenge of the untouchable.
We  do not think that the overall duration of the  therapy diminishes,  but we found for that patients that otherwise did not make any progress, the participation in a PMC acts like  a strong thrust forward  and gets them out of an ar÷ rested  life-situation  that sometimes already lasted  for more than a decade.  For other patients it means that they could  get  in touch with sides of themselves that  were deeply  buried inside them and they could otherwise have never worked through.
The Future of PMC's
It  must be clearly stated that PMC is an outsider  thera÷ peutic  approach. It does by no means represent the main stream  psychotherapeutic approach presently practised  in Germany,  though  certain elements of it are  increasingly integrated  in various hospital settings.  However, it is not been developed nor practiced completely outside of the "Zeitgeist".  It  corresponds to patient's and to  present social  needs. Humans that lacked a rich, varied  family life  with lively  and  interesting outside  interaction starve for a group experience that enables them to experi÷ ence  themselves as human beings encountering other  human beings to become able to experience who they are.
The PMC can become the basis of a process of internalizing of a highly differentiated large-group-matrix that eventu÷ ally lets the capacity grow to enter into new gratifying relations with others and with oneself to form groups,  to find new ways of relating to others, with whom one is able to  share one's feelings,  one's perceptions of the world, or  even one's deeds.  Simultaneously the PMC can help  to let grow a capacity for social concern and social partici÷ pation (Wallenberg, 1983, 84, 85) in order to become able to take actively part in the formation of one's social en÷ vironment and society.
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