Story of a psychotherapeutic relationship within an institutional context


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and not by chance the therapist can discover himself to remember his own childhood while the patient stays nearby and withdrawn into her glacial mutacism with a half the face covered by a long head of hair that goes down on her shoulders.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.


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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