Vol. 1, núm. 3 - Noviembre 2002
Revista Internacional On-line / An International On-line Journal
The "Loving therapeutic team"
José Guimón.
Catedrático de Psiquiatria, psiquiatra, psicoanalista, psicoterapeuta
Correspondencia:
E-mail: jose.guimon@hcuge.ch
Resumen
En el proceso del tratamiento psicoanalítico de los pacientes graves, en especial de los psicóticos, se
pretende inducir una regresión que permita un mejor cuidado del paciente (Guimón, 1985) para
actuar luego, a través de la interacción, permitiendo la reestructuración de su personalidad. Pero es
sabido que, en esa interacción, la transferencia psicótica, por el interjuego de identificaciones
proyectivas, produce en el terapeuta una contratransferencia bastante independiente de su
personalidad propia.
La enfermedad psiquiátrica amenaza la seguridad del individuo y los profesionales pueden ser figuras
temporales de "apego" que proporcionan un continente afectivo semejante a la función materna
descrita por Bion .
Los que trabajan en profesiones "de ayuda" (asistenciales) fracasan inevitablemente y repetidas
veces en su trabajo con clientes dañados y carenciados. Si este fracaso despierta culpa y ansiedad
intolerables, pueden, los profesionales (al igual que los bebés) retroceder a esas defensas primitivas
con el fin de mantener la precaria autoestima y defenderse de la retaliación que temen que se
producirá como consecuencia de su fracaso.
En adultos, se manifiestan tres estilos de apego inadecuado: "renunciador" (dismissing),
"preocupado" e "irresoluto", que se pueden evaluar con entrevistas semiestructuradas . Cuando
entran en contacto con los servicios de Salud mental, las personas "renunciadoras" pueden
encontrar díficil involucrarse en el tratamiento; las personas "preocupadas" pueden sentirse
bloqueadas o ambivalentes hacia la ayuda que se les ofrece; las "irresolutas" pueden tener dificultad
para gestionar los sentimientos dolorosos que produce el tratamiento. En cambio, las personas con
antecedentes infantiles de "apego seguro" se muestran más abiertas a hablar de sus síntomas y
suelen cumplir mejor las prescripciones medicamentosas.
En las unidades psiquiátricas se producen algunas situaciones que desencadenan en los pacientes
conductas de apego. Los propios profesionales pueden tener historias de apego inadecuado que
afectan a sus relaciones con los pacientes.Muchos pacientes con antecedentes de haber sufrido
abusos provocan en los profesionales conductas de exceso de vinculación. Por otra parte, ante
reacciones hostiles de los pacientes éstos pueden experimentar contratransferencias intensas y
utilizar, por ejemplo, medidas de contención inadecuadas. Si ellos fueron a su vez objeto de abusos
por parte de sus padres o educadores pueden tener tendencia a abusar de sus pacientes física o
sexualmente de forma más o menos clara o encubierta.
Se supone que el equipo terapéutico debe representar para el paciente una alter familia que le
permita una "experiencia emocional correctiva" de aquellas otras experiencias que pudieron tener
una responsabilidad en el origen de su padecimiento. Sin embargo, en el equipo terapéutico existen
dificultades diversas, derivadas unas de elementos de realidad (estrés del trabajo, rivalidades
profesionales, etc.) y provenientes otras de las identificaciones proyectivas que los pacientes han
depositado en los terapeutas. Por un fenómeno de splitting, los terapeutas depositan en los
enfermos todas las partes enfermas que rechazan en sí mismos. En esa situación de negación, rara
vez el equipo tiene la flexibilidad suficiente para adaptarse a las variables necesidades de los
pacientes.
Como dice Racamier, el equipo terapéutico puede llegar a sentirse disociado por esas proyecciones.
La tensión en los equipos de trabajo aumenta y sus miembros pretenden a toda costa aparentar un
perfecto entendimiento entre ellos, para presentarse como una "familia ideal", un continente en el
que pudieran crecer los pacientes. Esa necesidad de los componentes del equipo terapéutico de
simular que funcionan como una familia feliz, les lleva a mantener con firmeza, como hemos
comentado en el anterior capítulo, un ideal igualitario antiautoritario en el que todos los
componentes del equipo son iguales, negando las obvias diferencias de formación profesional y de
personalidad. En tales situaciones, no es infrecuente que tal seudoigualitarismo tienda a expandirse
también a los pacientes, a quienes teóricamente se les considera capaces de asumir sus
responsabilidades, aunque en la práctica y en forma encubierta, el equipo terapéutico actúe como si
los enfermos no fueran capaces de asumirlas. Se produce entonces lo que Sacks y Carpenter (1974)
han denominado "comunidad seudoterapéutica", que tiene mucho que ver con el concepto de
Winnicott de "falso self".
Winnicott redefinía en su libro Playing and Reality el concepto de "madre suficientemente buena":
"La madre suficientemente buena es aquella que realiza una adaptación activa a las necesidades del
niño, adaptación que disminuye gradualmente, de acuerdo con la capacidad creciente del niño de
asumir sus fracasos de adaptación y de tolerar los resultados de la frustración".W. Ralph Layland
subraya que una de las cualidades de la madre suficientemente buena es su capacidad de aceptar
que el niño tiene derecho a transmitirle todas sus necesidades, deseos, fantasías y sentimientos que
experimenta como buenos o malos, placenteros o displacenteros; pero también la de no esperar que
su niño acarree con las necesidades, deseos o sentimientos más o menos inconscientes de la propia
madre, que son inapropiados para la relación madre-niño y para los cuales ella debe buscar
satisfacción en otro lugar". Por ejemplo (continúa este autor), es un derecho del niño el llevar a su
madre sus propios sentimientos depresivos y el esperar que ella le ayude con ellos. No es, en
cambio, tarea del niño el soportar a una madre deprimida. Es a esta cualidad de la "madre
suficientemente buena" a la que Layland llama "madre amorosa".
En ese mismo sentido, se podría hablar de un "equipo terapéuticamente amoroso" cuando es capaz
de asumir las necesidades de los pacientes y de evitar hacerles acarrear las dificultades propias de
los componentes del equipo.
La modificación de los roles profesionales tradicionales para disminuir la rigidificación suele encontrar
resistencias, especialmente entre los profesionales más entrenados, que prefieren trabajar en un
encuadre donde su autoridad sea reconocida y alabada. Cuando el equipo trabaja en condiciones
ideales, aunque el psiquiatra es el responsable último del diagnóstico y de la prescripción de
medicación, no tiene más autoridad en cuanto al tratamiento que otro miembro del equipo, ya que
esas decisiones se realizan entre el equipo y el paciente. Sin embargo, es frecuente que problemas
de poder se diriman en discusiones sobre la orientación teórica: utilización o no de los
psicofármacos, orientación conductista, dinámica o sistémica, psicoterapia individual o de grupo, etc.
El grupo de supervisión es especialmente útil cuando es dirigido por un líder ajeno al programa y
cuando no se convierte en un simple ritual institucional, tal como lo hemos descrito en el anterior
capítulo. Una forma particular de trabajo es la tutoría por la que cada profesional tiene un tutor.
Se dirá que la inestabilidad de los cambios antes propuestos en los equipos los hace vulnerables.
Pero la vulnerabilidad de los mecanismos asistenciales comunitarios es precisamente, a mi modo de
ver, un lamentable prerrequisito para su éxito. Algo así como la tolerancia a la ambivalencia y a la
frustración y la aceptación de las resistencias son requisitos indispensables en la personalidad y en la
educación del psicoanalista.
Summary
In seriously ill patients' psychoanalytical treament process, especially psychotics, the professional
first aims to induce a regression which will make it possible to take better care of the patient
(Guimon 1985) in order to then, through interaction, enable him to restructure his personality.
However, it is well known that in this interaction, psychotic transference, due to the interplay of
projective identifications, produces in the therapist a countertransference quite independent of his
own personality. The author contends that a a "good enough team" (Bion) or even 'loving
therapeutic team' (Laylland) should be able to take on the patients' needs and avoid making them
deal with the team members' own difficulties.
1. REGRESSION IN TEAMS
In seriously ill patients' psychoanalytical treament process, especially psychotics, the professional
first aims to induce a regression which will make it possible to take better care of the patient
(Guimon 1985) in order to then, through interaction, enable him to restructure his personality.
However, it is well known that in this interaction, psychotic transference, due to the interplay of
projective identifications, produces in the therapist a countertransference quite independent of his
own personality.
Some situations created by different psychotic patients seem to be dominated by what has been
termed 'projective counter-identifications' (Grinberg 1962). Indeed, the therapist's role is that of
receiving the patients' projections, elaborating them, and enabling them to be introjected once they
are transformed. However, with psychotics the therapist is often compelled to act
countertransferentially, as if moved by these nuclei deposited by the patient's projective
identifications and which acquire, within the therapist, a life of their own, if he is not able to perceive
them, elaborate them, and transform them.
The therapeutic team should represent, for the patient, an alter family, which enables him to have a
'corrective emotional experience' to remedy other experiences that may have been responsible for
the origins of his illness. However, there are different difficulties within the therapeutic team, some
stemming from reality elements (e.g. workplace stress, professional rivalries), others from projective
identifications that the patients have deposited in their therapists. Due to a splitting phenomenon,
therapists deposit in their patients all of the sick parts that they reject in themselves. In such a
situation of denial, rarely does the team have sufficient flexibility to adapt to patients' varying needs.
As Racamier (Racamier 1983) saw it, the therapeutic team can come to feel dissociated by these
projections. The tension in working teams increases, and their members try, at all costs, to look as if
they understand each other perfectly, to present themselves as an 'ideal family', a containing
environment where patients can grow. This need that the therapeutic team members have to
simulate that they function like a happy family can lead them to firmly maintain, as we comented in
the previous chapter, an anti-authoritarian, egalitarian ideal in which all of the team components are
supposedly equal, denying their obvious differences in professional training and personality. In such
situations, it is not infrequent for such pseudoegalitarianism to tend to spread to patients, who are
theoretically considered able to assume the teams' responsibilities, although in practice, and in a
hidden way, the therapeutic team acts as if the patients were incapable of doing so. In that case,
what arises is, in the words of Sacks and Carpenter (Sacks and Carpenter 1974), a pseudotherapeutic community, which has a great deal to do with Winnicott's concept of the false self
(Winnicott 1965).
2. THE GOOD ENOUGH TEAM
Winnicott redefined, in his book Playing and Reality (Winnicott 1971; Layland 1981), the concept of
the good-enough mother: one who actively adapts to the child's needs, an adaptation that gradually
diminishes, according to the child's growing capacity to handle his adaptation failures, and to
tolerate the results of frustration.
Layland (Layland 1981) stressed that one of the good-enough mother's qualities is her capacity to
accept that the child has the right to transmit all of his needs, desires, fantasies and feelings to her,
which he feels as good or bad, pleasant or unpleasant; but she also needs to not expect her child to
deal with the more or less unconscious needs, desires, or feelings of the mother herself, which are
inappropriate to the mother-child relationship, and for which she should seek satisfaction elsewhere.
The example that Layland gives of this is the child's right to bring to his mother his own depressive
feelings, and expect her to help him with them. It is not, however, the child's task to deal with a
depressed mother. The good-enough mother, in Layland's terminology, is a 'loving mother'.
Along these same lines, we could call a 'loving therapeutic team' one that is able to take on the
patients' needs and avoid making them deal with the team members' own difficulties. However, just
as the function of the 'loving mother' is not, according to Winnicott, the only function of a goodenough mother, there are other functions that are demanded of a good-enough team: teaching
appropriate reality management, self-care, care for others, and so on, some of which could be
adscribed to the functions of a 'good-enough father', who has yet to be described.
The therapeutic team should, in addition, from a utopian viewpoint, try to create an imaginary
space, one for preconsciousness, an 'illusion' in Winnicott's sense of the word -- which is, in reality,
the space of creativity and psychoanalysis. However, it is self-evident that none of this is exactly
simple.
In 1963, President John F. Kennedy of the United States offered a great deal of funding to
psychiatric centres for creating new units inspired by the ideology of community psychiatry.
Hundreds of centres of this kind then sprang up like mushrooms all across the country, with the aim
of getting their hands on this economic aid. Since the 1970s, I have visited dozens of centres of this
kind, in different areas of different countries. The typical image of an activities session in one of
these programmes could be that of a young mental health worker, trying, with an expression of
cheerful enthusiasm but clearly bored inside, to get a few defeated-looking chronic patients to form
a band, docilely sawing away at some musical instruments.
Between a costly set-up whose efficiency is merely that of a child-minder, and an exceptionally
valuable therapeutic setting, the difference is the existence of a space for illusion, and the presence
of a good-enough therapeutic team.
3. THE TEAM COMPONENTS AS ATTACHMENT FIGURES
Psychiatric illness threatens the individual's security, and professionals can be temporary attachment
figures who provide an affective holding environment similar to the maternal function described by
Bion (Bion 1962). Through sympathetic listening, they help the patient to develop the capacity to
think and to tolerate anxiety, using their own mental processes to hold and digest the patient's
projections.
In children (Ainsworth 1969), different attitudes of insecure attachment (avoiding, ambivalent, and
disorganised) have been described, which, when they interact with other vulnerability factors, can
predispose them to psychiatric disorders. Many adults seek to help others because they themselves,
in infancy, experienced inadequate attachment, leading them to have a need for compulsive caring,
which is seen in some professionals. The problem is that some of these professionals are hesitant to
accept that they have difficulties or to seek help, which leads them to suffer from substance abuse of
'burnout'
Normally, having discovered many times that the mother, and later, others survive his attacks, the
child learns to have confidence that his love dominates his hate, and that his reparation activities are
successful. This reduces his fears of persecution and retaliation by the bad mother whom he has
attacked. But when external reality fails to refute the child's anxieties, for example, if the mother
dies, or retires, or retaliates, then the depressive anxieties can be too heavy to be borne. The
individual then abandons his failed reparation activities, and recurs instead to more primitive
paranoid, manic, and obsessive defences.
Those who work in the 'caring' professions often, and inevitably, fail in their work with damaged and
needy clients. If this failure sparks intolerable guilt and anxiety, these professionals (like infants)
may regress to these primitive defences with the aim of maintaining their precarious self-esteem,
and defend themselves from the retaliation they feel is coming to them for failing to effect a cure.
In adults, there are three main styles of inadequate attachment -- dismissing, worried, and
irresolute -- which can be assessed with semistructured interviews. When they enter into contact
with mental health services, those with a dismissing style may find it difficult to get involved in their
treatment; the worriers may feel blocked or ambivalent about the help that is offered to them; the
irresolute may have difficulty managing the painful feelings that treatment produces. However, those
with childhood antecedents of secure attachment show themselves more open in talking about their
symptoms, and tend to present better pharmacological compliance.
In psychiatric units, some situations can set off attachment behaviours in patients. They may, for
example, feel excessive fear of leaving the hospital, and their symptoms may worsen when the time
comes to do so. If one of the unit's professionals leaves, this can also produce, in patients who were
attached to him or her, adverse reactions which can manifest themselves in the form of aggression,
explosions of violence, or other ways, all inadequate attempts to keep that person from going away.
The professionals themselves may be dealing with histories of inadequate attachment, which affect
their relationships with patients.
Many patients with antecedents of having suffered abuse provoke excessive attachment behaviours
in professionals. However, hostile reactions from patients may lead professionals to experience
intense countertransferences, and use, for example, inadequate holding measures. If they
themselves had been subjected to abuse by their parents or educators, they may have a tendency to
physically or sexually abuse their patients in a more or less open or hidden way (Gabbard 1995).
Mental institutions themselves can become attachment figures for patients who did not experience a
secure attachment in infancy. Attachment to professionals and institutions can sometimes persist for
long after the patient has left them.
Professionals should provide patients with a secure base, an affective holding environment able to
modulate their anxieties. It is more a matter of being with patients more than doing things to
patients.
4. VICISSITUDES IN TEAMS
4.1. Rivalries
Since the beginning of the community psychiatry movement, strong tensions and rivalries have
arisen among the team members. Within a 'democratic' therapeutic setting that promoted the
equality of its personnel (e.g., everyone conducted psychotherapy, everyone was involved in
decisions about the patients' future), there were, however, obvious differences in training and
status: salaries varied a great deal according to individuals' academic level; physicians continued to
be the ones who were legally responsible for treatment, involuntary hospitalisation, and reports for
legal trials and payment of interventions.
During the 1960s, the development of the community mental health system provoked an overload in
the number of professionals, their respective roles became quite diffuse, and everyone was
considered a 'therapist', with or without the proper training. Psychoanalysis was the favourite
psychotherapeutic treatment in the 1960s, and the therapeutic model around which most of
psychiatrists' training revolved. In the United States, therapists who were not physicians had no
right to practice psychoanalysis, and in Europe the legal situation was similar. However, in the mid1980s, a result of a judicial action on the part of the American Association of Psychologists,
psychiatrists could not continue to monopolise the psychotherapeutic treatment of ambulatory
patients. Thus, psychiatrists soon found themselves moving over to make room for non-medical
therapists (Fink 1996). In the meantime, the transition had already been made in Europe, without as
much trauma.
In this context, major conflicts arose over the psychiatrists' desire to reserve for themselves the
function of psychotherapy, excluding psychologists, social workers, psychiatric nurses, and
occupational therapists, whose role in community mental health centres was, in their opinion,
becoming too prominent. Enriquez (Fink 1996) points out that today, in such teams, every
professional, from the psychoanalyst to the teacher, plays a therapeutic role, all believing that they
have a right to 'function like "influence machines" (Tausk) who try to modify some behaviours of
those "assisted", in different and contradictory ways. Some wielded more "influence than others, and
even, when getting the patients to talk, try to show the preference that the patients have for them. .
. . The patients experience a contradictory situation, one that drives them insane, and they find
themselves immersed in a process of fragmentation, not construction, since they are not supported
in their experience by an organising law, but feeling directly in their psyches and their bodies the
violence of the institution's fragmentation, incarnated by its members' rivalry and narcissistic selfaffirmation.'
4.2. Excessive expectations
When community health teams were started up, everyone thought they would be so attractive that
most of the best and brightest psychiatrists would leave psychiatric hospitals to work in the new
centres. However, it soon became clear that the level of satisfaction of those working at the
community centres was lower than anyone had anticipated. And the situation has not improved over
the years.
A great many of the conscious choices made by mental health professionals are based on idealism.
However, these ideals also have unconscious determinants that can contribute to generating
defensive institutional processes.
Zagier Roberts (Roberts 1994) provides examples from her experience as a supervisor of
dynamically oriented institutions, where she observed serious relational difficulties among some
professional groups; for example, between nurses and psychotherapists. One of these centres
(Fairlea Manor) was one of the few hospitals where there was a psychoanalitically-based therapeutic
programme, and some therapists had gone to work there because they passionately believed in this
approach. They wanted to ignore the fact that the environement had changed drastically since the
1940s, when patients could stay at the centre indefinitely if necessary, whereas now, insurance
companies are demanding that the length of stay be held to a minimum. Many professionals were
still in analytical treatment as part of their training, and had a deep need to believe in its efficacy.
They felt that the survival of their speciality was threatened by the decline in psychoanalytical
psychotherapy in psychiatric institutions, and they had set for themselves the impossible task of
proving that they could cure any mental illness, no matter how serious, with this technique. This led
to a splitting of the doubts that they had, which they projected onto the rest of the centre's
personnel. This splitting also involved their rage towards those patients who 'refused to get better',
and they accused the hospital of not providing the resources -- especially, unlimited times -- that
they believed would enable them to carry out their impossible self-assigned task. They wound up
basing their search for self-esteem on showing disdain towards the other professionals, who were
trying to achieve a superficial improvement in the patients.
This disdain, even hatred, of external reality is typical of the 'basic assumption' group functioning
mode (Bion , 1961), in which the task that the group is trying to carried out involves seeking to
satsify its members' internal needs more than the work for which it was created. It is associated with
an absence of scientific curiosity regarding group efficacy, and an inability to think, to learn from
experience, or to adapt to change (Bion 1961).
Another of Zagier Roberts' examples is that of a residential unit for children who were separated
from their families for their own safety, whose aim was to prepare the children to return to family
life, whether with their biological parents or adoptive ones. According to its personnel, no parent was
good enough to take care of a child, so that nearly all of the discharges were traumatic.
The impossible self-assigned task, in this case, seems to be to provide the children with the 'ideal
parents' that they never had. The unresolved problems of the centre's personnel (several had been
in such centres themselves, or came from broken homes) led them to identify excessively with the
children, and believe that everything good and useful was within the organisation, and everything
harmful and dangerous was in the outside world. Many teams and organisations are created as
alternatives to other, more traditional ones, often by someone discontent with previous personal or
professional experiences in other contexts. However, an identity based on being an alternative,
better according to ethical or humanitarian criteria, tends to smother internal debate. Any
questioning within the group is considered a betrayal of the new proposal. Inevitably, problems arise
when the alternative approach turns out to be fallible. Working with chronic schizophrenics or with
abused children or heroin addicts is intrinsically difficult, and success is never as great as one hopes.
The alternative approach is based on a risk hypothesis, according to which, by merely changing
certain conditions, extraordinary success will be achieved.
4.3. Dealing with patients
'Insanity is contagious': this cliché has been repeated ad nauseum, and the idea is that those who
deal with mental patients wind up getting tired of them, and that professionals have as many
prejudices about their patients as the general public does. But what are the characteristics of
patients that feed professionals' prejudices about them?
Eker y Oner (Eker and Oner 1999), in a study of fifth-year medical students, found that the severity
and aggression of a patient's behaviour was related to worse acceptance. They also found, in the
responses from various categories of profesionals, that the characteristics that contributed to a
perception of treatment difficulties were: psychosis, severe pathology, suicidal-depressive behaviour,
and violent agitation. Those who were perceived as improving less and who had a poor prognosis
were considered particularly difficult.
On the other hand, there is a real risk of physical aggression in the context of working with
psychiatric patients. Kaës (Kaës 2000) points out that professionals can be both physically and
psychically attacked by their patients, but they are also the object of attacks against the tie that
binds them through sucide attempts, criminal acts, and acting-out, which place them in a situation in
which they feel destroyed in their action and in their being.
4.4. Attacks against creativity
Some creative activities of certain professionals, although they are to a large extent the result of the
institution's overall creativity, are not accepted by the institutional climate prevailing at a given time.
Professionals then think that these creative activities cannot be carried out because the institution
has other projects, without realising that they are the real actors, and that the institution is nothing
more than what they do. Professionals wind up carrying them out surreptitiously, and, as Enriquez
(2000) puts it, 'they feel guilt every time that they are creative, since they have the feeling of
transgressing against the sacred values to which they adhere. . . . Occasionally, they ignore the
rules and act in a way other than the predictable one, but wihout daring to say it, for fear of beeing
negatively evaluated . . .; they then begin to act in secret . . ., fearing that the truth about their
actions will come to light, and that others will become their persecutors . . .; patients perceive the
contradictions between intentions and actions, and they feel like part of a generalised lie, with which
the therapists always make them accomplices.'
5. STRATEGIES FOR HELPING TEAMS
In the process of constituting a community team, or in an attempt to change a team that functions
according to a classic model into one using a new model, it is necessary to modify antitherapeutic
attitudes learned from previous roles, and also to create less rigid ideas about each individual role. A
fundamental part of this is to attain a common attitude regarding the understanding of psychiatric
patients, which will enable the worker to take on new roles, and form more significant relationships
within the framework of treatment. For such an effort to be successful, it is advisable for the team
members to interact with patients, including them in some of the team's activities and organising
social activities within the center itself, or trips and excursions sponsored by the programme.
However, relationships outside the centre are not advisable.
The modification of traditional professional roles to diminish their rigidity tends to meet resistance,
especially among the more highly trained professionals, who prefer to work in a setting where their
authority is recognised and praised. When the team works under ideal conditions, although the
psychiatrist is the one ultimately responsible for diagnosis and prescribing medication, he has no
more authority regarding treatment than any other member of the team, since these decisions are
made between the team and the patient. However, power problems are often channelled into
arguments about theoretical orientation: whether or not psychopharmaceuticals should be given;
whether a behavioural, dynamic, or system approach should be used; individual versus group
psychotherapy, and so on.
It is in the practice of psychotherapy where, as we have mentioned earlier, power problems most
often arise among team members. There are frequent objections on the part of psychologists and
psychiatrists to sharing any of their psychotherapeutic functions with nurses, whom they do not
consider adequately trained for these functions. For their part, the nurses sometimes resist taking
part in theoretical or supervisory programmes, especially if they are directed by the team's most
highly trained professionals.
The supervisory group is especially useful when it is directed by a leader from outside of the
programme, and when it does not become just another institutional ritual, as described in the
previous chapter. A particular method of working is that of mentoring, under which each professional
has an assigned mentor.
In any case, perhaps, and just as, for women, there is an ideal age for mothering a baby,
therapeutic teams also have their time limits. Everyone knows that a psychotherapist working with
psychotics has close theoretical and practical relationships with child psychoanalysis. Often, child
psychoanalysts work enthuasiastically with children for some years, and then tend to quickly
abandon working with them directly and draw back to a more comfortable supervising position. A
similar phenomenon can be seen among therapists specialised in psychotics.
The therapeutic team also has a time limit on its capacity for illusion. That is why, in our view, the
staff of such units should never be long-term, but rather easily renewable, predominantly by new,
young, enthusiast therapists. A young, uncultured mother often takes much better care of her
longed-for baby than a psychology professor does of her own unplanned last-born child.
We could say that the instability of the changes suggested above would make teams vulnerable. But
the vulnerability of community health care mechanisms is precisely, in my view, an unfortunate
prerequisite for their success. Just as tolerance of ambivalence and frustration, and acceptance of
resistance, are indispensable prerequisites in the personality and education of a psychoanalyst.
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