When the psychotherapist begins to treat a patient as
Antonella, 22 aged - we will call her "Red Bootees" for her way
of dressing (red bootees, red bodice, flared black skirt) - he immediately
has the feeling to have met a not quite psychically integrated person and
whose thoughts develop on a so rudimentary level to make her often
incapable of fully differentiating the external reality from the inside
objects produced by the imagination.
The patient’s fragility can rouse some therapist’s delicate feelings
of tenderness, analogous to those that children arouse when they are very
little ones; and not by chance the therapist can discover himself to
remember his own childhood while the patient stays nearby and withdrawn
into her glacial mutacism with a half the face covered by a long head of
hair that goes down on her shoulders. The worry - that the patient’s Ego
can further fragment - forces the therapist to a continuous attention,
because he is afraid of making some mistake in his own attitude or words,
so only rarely he can feel freer.
On the other hand the patient hardly give him a way for relaxing: during a
session she seems to go out her autistic dimension, she is opening out the
communication, she is gratifying the therapist’s efforts to diminish the
interpersonal wall and, instead, the successive session Antonella is
visibly depressed, totally inaccessible; now she has changed look: she
wears yellow bootees and violet trousers; her hair, the first session held
picked in two plaits that freed her face, now they darkly cover her eyes;
there is a deathly silence.
The psychotherapist has the feeling to be faced with a person that has
lost the logical categories through which the experiential universe is
ordered: probably the time has become only body-movement; the places have
perhaps assumed strongly symbolic values unfolding long surreal dimensions.
Antonella, whose mother has been for a long time hospitalised since
suffering from schizophrenia, gives the impression as to try to orient
herself in a labyrinth (an intricate mixture of relationships and objects
that has been interiorised) within which her Self seems irremediably lost
because lacking in a sufficient differentiation. The psychotherapist,
during the sessions, himself has the sensation of an insufficient
differentiation of his Ego, as a loss of the personal identity that,
therefore, he tends to quickly recover for not living himself a psychotic
experience; the fear of this experience reactivates, in extraordinary way,
his rational and conscious processes which, so mobilized, become the
principal impediment to the development of a therapeutic relationship that
can happen on a deeper level.
In a following phase, four months have lapsed already, the silence during
the sessions is well accepted by both the partners of the
psychotherapeutic process. To this it concurs, over the need to avoid the
intense anguish that can mobilize in both every exploration that digs up
the drama of the patient’s existential reality, also the deep
gratification, in the symbiotic phase of their therapeutic relationship,
arising from some emotions and feelings that hardly can be expressed as
rational thoughts or put into words, because they are lost representations
that unlikely can be relieved since belonging to archaic epochs of the
individual development.
One day, finally, happens that the patient arrives quite smiling and she
shifts freer inside the session’s therapy-room, so she can easily get up
and approach the window to look out the soaking rain. The psychotherapist
feels that the patient is becoming fond of him and he wonders if Antonella
is not unconsciously day-dreaming of a mother that draws near her and
laces her to the breast. But when the following session she appears again
visibly sad and dark, the therapist feels disappointed, frustrated; he
thinks his assignment as an huge, an endless waiting, save for taking some
notes and at intervals offering her some verbal help, but with the
sensation that the most greater part of his words had to fall in the void
without leaving any trace.
Other times Antonella seems to be revitalized; she is through her sighs,
as a "Sleeping Beauty in the wood" who is waking up and freeing
herself from the deadly spell. During this phase the patient seems to
search a personal shape; when she decides to orally communicate something,
she repeats a same word three times, in the beginning with a whisper, then
in a low voice, finally with a normal tone of voice. She has changed look
again: black skirt and blouse, white bootees, hair woven as a Viking
woman; a constant veiled smile on the lips.
The psychotherapist feels a tenuous resurfacing of some her forgotten
seductive and erotic dimensions, a comeback of her libido and sexuality.
In the following sessions Antonella seems scarcely to tolerate that the
therapist takes notes and she starts to look fixedly at his face; after
some days, while he is taking some notes, the patient draws very near him,
almost to want an epidermal contact and a human heat through the bodily
proximity. In spite of everything the psychotherapist have to recognize
that, after different months of treatment yet, he has not succeeded in
modifying the Antonella’s tendency, during the sessions, to maintain a
practically absolute silence. It comes to his mind that unconsciously
himself has perhaps feared that this steadiness can modify, as if the
abandonment of the silence can facilitate a remerging of the Antonella’s
primary anguishes, those that have made her so psycho-emotively vulnerable.
In the course of time Antonella seems less and less confused and has a
different attention towards the surrounding environment; in fact she
starts to observe a lot of things: the room-furniture, the books on the
table, the cover drawings. But they are least changes because Antonella
tends overall to maintain with the therapist a relationship as if with her
schizophrenic mother.
Afterwards around seven months from the beginning of the therapy the
patient shows further ameliorations; she has finally started to converse
with the therapist, even if in hesitant and disconnected way; but however
she only speaks of suits, fashion and hair styles. Nevertheless, some
sessions later, unexpectedly, she invites the therapist at her home, she
would offer him a coffee; she adds that even if she is not living alone
however she feels herself very alone. The patient, that has developed for
a long time views as if persecuted by her own relatives, sees evidently
the therapist as a befriends and protective figure.
Antonella is not able up till now to face a more analytical work, in fact
the interpretations or the asks for favouring a greater her insight they
regularly provoke stereotyped escape behaviours; on these occasions the
patient gets up suddenly and goes into the waiting-room to get one
cigarette for immediately returning with a lighted cigarette. The only way
to avoid these behaviours is to maintain an apparently passive position,
to succeed in acting as a container of the not-said, to function as a sort
of collector of the most confused and darkest patient’s parts. This
necessity of self-limitation provokes inside the therapist an enmity
bother of which now he can more become aware.
Around ninth month’s therapy, during a session, Antonella presents
another novelty. She takes a magazine placed on the desk and she starts to
leaf through it; at a certain point she seems attracted and upset by an
imagine on which she pauses for a long time. The therapist is enough
happy; it is the first time that he sees his patient as intensely
interested in something; it is also the first time that she does not ooze
any fatuous emotion or defensive dulling. But the session later and in the
course of the following others, Antonella shows the usual attitudes, like
an all smiles and sweet eyes "little mermaid”. Only once it happens
something different: Antonella seems intent to study her therapist and to
try to understand him, perhaps also she desirous to help him as if she had
felt him in trouble or in need of support.
Just about the tenth month’s therapy, during a session, all at once the
patient addresses the following sentence to the therapist "Until now
you has not helped me" and then she adds "Could you visit me? I
have the inflamed uterus; Could you help me? I need a perfect uterus, one
not diseased; I believe that I am ill because of the inflammation; I don't
know! To make love can hurt: one can become pregnant by a drop of pee!".
And the successive session the patient points out her own abdomen saying
that it is hurting her. The therapist understands that, beyond the
patient's fantasy/desire to be pregnant, she is recovering herself bodily
and that her somatic re-personalization cannot happen without a certain
pain.
After one more month, the therapist is inclined to think that - when
Antonella gives the answer "nothing" to the invite to
communicate what she is thinking - her answer can have now a different
meaning from the period when the patient showed an enormous difficulty to
“think her own thoughts”. Now the same answer can be interpreted also
as a form of resistance, since the patient seems to have acquired a
greater conscience of herself and a lesser precariousness of the feeling
of personal identity.
Toward the end of the twelfth month, it occurs an unforeseen interruption
of the treatment. In fact, without any prior notice of it the local health
corporation forces the therapist, in spite of himself, to utilize the
whole so far gathered ordinary lave for replacing him with a more elderly
colleague who was fidgety to do a brief experience about the territorial
psychiatry.
The psychotherapist’s absence from the out-patient service is not
excessively long (not much more than one month) but it is enough for a
Antonella’s, who in the meantime had not been cured by any psychiatrist,
plunging back into the initial psychic state; also because the patient's
father – who formerly had regularly accompanied three times a week his
daughter to the out-patient centre for the sessions – now. also having
formally accepted the recommencement of the treatment, finds the way,
producing every time some justification, to skip the most greater part of
the appointments. So the meeting between Antonella and her psychotherapist
becomes a absolutely sporadic event. To this also Antonella concurs, on
her part, making endless the preparations every time she has to go out of
house, just as this happened in the beginnings of the treatment.
The psychotherapist could perhaps try to continue his work transferring
the session at home of the patient, but various considerations induce him
to reject this idea. Firstly, the worry that further possible bureaucratic
interventions can again thwart the therapeutic efforts and to provoke a
patient’s new psychic regressions; besides, the worry that the
transferring the sessions to patient’s home can be a change too radical
in comparison with the former psychotherapeutic setting and that such
change can eventually arouse in the patient - who had also tried the
suicide in the past - some possible psychopathological emergencies, hardly
controllable without the support of a territorial équipe able to give, in
case of need, a suitable domiciliary assistance to integration of the
psychodynamic therapy; at last, probably, over the awareness of a quite
impedimental therapeutic context, on a less aware level, the stress for
the earlier psycho-emotional therapeutic weight and the increased worry
(naturally
in a right dose it is generally present in every psychotherapy) for a
possible unsuccessful treatment.
******************
COMMENTARY
by Alfredo Anania
******************
The above narrated case leaves a sour taste in reader’s mouth on more
scores that one: first of all, a treatment that, despite the clinic
intricacies, seemed enough promising it is interrupted however and the
patient, who appears fragile because of her illness, give the impression
to be irremediably destined to plunge back into her psychotic defensive
shell; secondly, to the patient’s frailty corresponds a some
psychotherapist’s frailty, in the sense that the treating psychiatrist
appears easy to the discouragement and lacking in that ability to however
maintain with the necessary constancy a therapeutic relationship, this
also in consideration of the visibly positive transfert and of the
compliance, since the beginning of the psychotherapy, shown by the patient
even if in a sui generis form because of her psychosis; in the end, it
seems paradoxical the local sanitary administration’s way of interfering
on the psychiatric service’s operational organization and, therefore,
indirectly on the therapeutic relationship, in a so bureaucratically wild
form to appear incredible if it weren’t so dramatically true that
not-infrequently within the public health (and perhaps also within the
private) service many, extraneous to the care and to the therapeutic
relationship, factors intervene that are more closely connected to
power’s playing, wheeling and dealing … and such.
Never it is enough to repeat the fundamental importance of the “équipe
work” with reference to the psychiatric institutions, in fact,
classically “the équipe work is necessary when the one’s strengths
are not enough”! From long time it is affirmed the idea that is
preferable a multi-modal work by the équipe that can functionally operate
intervening on different levels for treating the psychoses (therapy
pharmacology and individual psychotherapy, group therapy, family therapy,
art-therapy, occupational therapy, techniques of rehabilitation and
re-socialisation) by means of a planning decided by équipe’s periodic
reunions finalized to collegially discuss and to evaluate the clinical
evolution of the case and to coordinate the interventions considered as
necessary. It is evident that two conditions are essential to the good
operation by the équipe as a work group: the first one is that the équipe-leader
has a suitable psychodynamic and group formation; the second is that all
the operators have a formation to the team-work. Formerly I have proposed
to replace the classical “orchestra” model, as a metaphor regarding
the team work, with the model of the “chess”: where every chessman can
perform only its peculiar “moves” and strategically stir in the more
convenient way (on the opinion of the player; evidently here on the
team’s opinion as a whole [“group mind”] considered). I believe that
the model I have proposed has the advantage to not-confining the team to a
role in some way of passive execution - as the orchestra does about
musical-scores, that sometimes can be also sublimely interpreted but
generally composed by others; on the contrary, the metaphor of the chess
valorises the team’s possibility to operate through a strategic and
creative “mind” that predisposes the multi-modal operational
interventions in a coordinated way and with versatile adaptation to the
effective (clinic and eco-systemic) evolving reality.
Unfortunately they are still very rare the psychiatric institutions
predisposed to shelter for a long time psychotic patient treated with
intensive analytical psychotherapy (five days a week for one period that
varies between the 5 and the 15 years, according to the gravity of the
clinical case) till the possible recovery and where the whole staff has a
considerable level of psychodynamic formation (for instance, also the
nurses have in their formative baggage one or two years of personal
analysis). The reference to similar hospitals or therapeutic communities
can also be useful to quote psychiatrist-psychoanalysts, as for instance
Harold F. Searles, who have devoted their professional life to the
psychoanalytic treatment of the psychoses and whose publications, it is
sufficient to mention the Searles’s "Collected Papers on
Schizophrenia and Related Subjects" (The Hogarth Press and The
Institute of Psychoanalysis; London; 1965), can clarify many deep
relationship dimensions (we can glimpse a few of them also in the
therapeutic story above reported) that happen both in the patient that and
the therapist during the intensive psychotherapy of a psychosis.
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