Psychoanalytic Milieutherapeutic Community
Andreas von Wallenberg Pachaly, Düsseldorf (FRG)
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.
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.
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.
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.
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.
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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