THERAPEUTIC AND NON-THERAPEUTIC COMMUNITIES
Dott. Ignazio Caltagirone
Dott. Marina M. Smargiassi
ABSTRACT: This paper illustrates the importance of some principles or functions of the
therapeutic community, characterized by five definitions or images of the community:
a) the community as the location of a therapeutic process;
b) the community as a setting;
c) the community as a maternal environment;
d) the community as training for life;
e) the community as a space for re-planning.
The analysis is based on the experience of both authors of this paper in the Maieusis Community
(of which they thesis. The authors also consider how anti-therapeutic or asylum-type community
models can arise, when in a therapeutic community the above-mentioned functions are absent or
conducted in a pathological way.
Introduction
Maieusis is a residential community near Rome which has been functioning since 1980 for the
therapy and rehabilitation of young psychiatric patients, psychotic or with serious personality
disorders, who are capable of making significant improvements and for whom out-patient
treatment is considered impracticable or insufficient. At present the community is home for 20
patients, sent to us by various national health authorities, and in addition provides support for 20
ex-patients in relatively autonomously run houses. The staff of the community consists of 15
psychologists, four nurses (for night-shifts), two psychiatrists and two psychotherapists for
conducting therapeutic groups and the supervision of individual cases. Three art teachers with
analytic experience also collaborate in running the expressive groups (writing and art-therapy)
and there is a psychotherapist for staff supervision.
Treatment in the community is limited to two years, and includes pharmacological treatment,
support, psychotherapy and rehabilitation. The community is divided into five family-type groups,
each one with four patients, in which a small team of three psychological workers ensure the
continuity of the therapeutic process during the day.
a) The community as the location of a therapeutic process
Psychotherapy requires the patient‟s collaboration, indeed he is the protagonist of this activity,
and one of the principles of the therapeutic community (TC) is that the patient should be the
active subject, rather than the passive object of therapy. This means not only that he actively
participates in the life of the community, but there is a deeper sense in which he is the actor of a
therapeutic process. Thus the TC is not simply a place for the treatment of illness ,but it is above
all a space for planning, in which the patient is respected as the arbiter of his own plans and
projects, even when he seems to be without willpower or motivation. Thus he takes part in the
therapeutic programme not because of his illness, which he in fact often has difficulty in
recognising, but in order to reach a personal aim. Only in this way can there be a meaning to his
stay in the community and he can avoid feeling segregated and impersonalised. Therefore, even
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before he enters the residential community, the patient must be helped to develop a therapeutic
plan. If the time of the patient‟s admission is anticipated, ignoring his own will in order to
conform with the pressing demands of his family members, the health authorities or the
community administration, there is a risk of the therapeutic process being sabotaged as soon as it
begins.
Since patients often deny their own needs and seem to lack any ability to make plans for
themselves, there is a tendency to ignore their will and deny this fundamental therapeutic concept.
To ignore, override or deceive the patient‟s will in order to get him into the community and into
receiving „treatment‟ is unfortunately a very widespread anti-therapeutic practice. In this way,
whatever principles it may proclaim, the community can become an asylum-like structure, often
with the patient‟s own complicity, since in this way he can feel himself entitled to not collaborate,
and to behave irresponsibly, with the consequential risk of damaging the emotional environment
of the whole community.
In the Maieusis Community, before entry on a residential basis, the patient takes part in a
series of preparatory interviews and undergoes a trial period. He then signs a therapeutic contact
(which he will tend to try to modify or even deny) in which he basically asks to participate in the
programmes of the community, pledges to respect the rules which he has already had occasion to
experience and specifies some of his needs and difficulties, as the therapeutic objectives,
individuated during the preparatory interviews, which he wishes to reach. He also declares that
developed a relationship of trust with his assistance workers, in whom he recognises a
„therapeutic power‟ and he subscribes to the time limits and periodical checking imposed. Also
the patient‟s family agrees to an analogous contract in which they undertake to engage in a
parallel therapeutic process.
It is not easy to use the instrument of the therapeutic contract, since the patient tends to deny or
continually try to ignore it and deny his suffering and his needs. He often has unrealistic and
omnipotent objectives (to deny his illness), secret objectives of revenge and violent impulses
towards himself, which must not be encouraged. If the patient, due to the nature of his pathology,
is attracted towards unrealistic and self-destructive impulses, how far can we respect his will and
how far should we oppose it, without damaging his therapeutic development?
It is therefore necessary to support and agree upon a minimum request for help from the
patient in order to generate in time, by means of comparisons and verifications, an evolution of
objectives and of a therapeutic process. It is necessary to sustain the constructive projects, while
fighting against the patient‟s tendency towards damage against himself, which is characteristic of
psychosis. The adherence of the patient to an effective therapeutic plan is evidently a valid point
of arrival, rather than a point of departure for the therapy.
In Maieusis the therapeutic plan is formulated and verified during the weekly sessions of the
small therapeutic groups (relating to the five family-type groups which make up the community).
Periodical meetings are also planned in order to create a sense of responsibility in all the people
involved in the contract: the patient, the assistance worker, the relatives, who often have an
ambivalent attitude and the health service which arranged for the patient to be sent to the
community and makes an economic investment for the patient to be re-integrated into society.
During these meetings there is an examination of the work being conducted, involving the
consideration of the results which have been obtained and the new objectives it is intended to aim
at.
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During the therapeutic process, as well as dealing with their various individual and personal
objectives, the patients find themselves going through a number of stages which are fairly similar
for all of them, and which force them to face frightening and painful experiences, tempting them
to abandon the therapy and subjecting them to serious decisional crises.
- The first stage entails being able to recognise, at least partially, the feelings of unease and the
need to be helped. It is necessary to be able to ask admission to the community, to gradually
accept the fact of participating in the programmes and to respect the setting.
- The second phase involves being able to entrust oneself to the assistance worker and
gradually abandon the defences of the false adult self in order to start getting in contact with a
regressed but genuine self.
- A third phase consists of being able to activate oneself (while renouncing illusions of power)
in order, at least partially, to rediscover lost capabilities, to experience, judge and give a value
to a more modest, but real image of oneself.
- A fourth and final stage consists of being able to find a realistic plan of re-integration in
society and positively separate oneself from the community, having repaired at least a part of
one‟s inner world.
(These four stages in the therapeutic process will be dealt with in greater detail later, since the
above mentioned therapeutic principles of the TC are based on them..)
We may conclude that for a community to be therapeutically effective and not an asylum-type
structure, it must favour a therapeutic process. To achieve this aim it must respect the patient‟s
will. This does not mean supporting or colluding with the unrealistic, illusory and self-destructive
aims which are always present in psychosis (and against which it is necessary to fight.) Instead it
means sustaining and accompanying the patient with determination in the realisation of his vital
and constructive plans, while always being sure about the fundamental and required stages of
the therapeutic process, which will lead the patient to experience and go through various, often
painful and frightening, decision making crises.
b) The community as a setting
With this image of the therapeutic community it is necessary for it be organised as a single
large setting in which the various individual or group activities are structured as sub-settings,
each with its own precise limits, including places, times, rules, programmes and working
methods. This is necessary to contain anxiety, channel aggression, sustain the functions of the ego
of the patients and make it possible to observe the complex psychic phenomena which take place
within the community.
Life in the community is extremely complex and there is a risk of it becoming chaotic if there
is no structuring or control of the times, places and methodologies of the various activities which
are conducted there. Every activity (care of the person and his room, the running of the house,
periods of living together, therapeutic and expressive groups autonomous spaces, etc.) has a
specific aim which defines both the task which the patient must perform, and the work of the
person who is treating him. A structured setting imparts order, precise reference points and
predictability to events; everyone knows what they must do and this is reassuring for the patients
(and also the staff). In particular during the phase of admission and settling into the community,
patients need to have clear reference points, to know the limits and the roles, what they must do
and not do in order to feel „at ease‟, and not internally criticised or persecuted. The lack of
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organization of activities, roles and work, which characterized the first years of the Maieusis
community‟s existence, made us realize that spontaneity produces a climate of precariousness and
a temporary feeling which leads the patients to move away from the structure and indulge in acts
of damage against themselves.
The programmes and activities are also necessary to engage the patient‟s energies, channelling
actions and thoughts into constructive and concrete objectives to be pursued on a daily basis.
External limits help the patient to discover his internal limits, to discipline himself, to structure
his time in a more healthy way and to contain the fear of emptiness which is so common among
our patients. The setting also protects the support worker from being swallowed up by the
patient‟s continual demands, and being dragged into games of power which threaten to
compromise his relationship with the person under his care.
The setting acts as a mirror to the patient‟s internal limits. Through the expressive, socio-
rehabilitative and psychotherapeutic activities, as well as the autonomous running of the house,
he can gauge the extent of his capacities and measure his expressive, relational, introspective and
working difficulties. Within a well organised setting the support worker can deal with those
functions lacking in the patient‟s ego, first of all by substituting for him in carrying out his tasks,
and then by supporting him to a gradually lesser and lesser degree, during the rehabilitative
process. The setting thus operates as an external replacement for the internal structures the patient
lacks.
The precise limits and the daily or weekly regularity of all the activities comprise a structure
of reference which allows the observation and control of the complex variables of the setting and
permits research to find the factors which can optimise the therapeutic treatment. The Maieusis
Community has therapeutic treatment. The Maieusis Community has created a system which
measures the degree and the quality of the patient‟s participation in the various psycho-socio-
rehabilitative activities of the community. This system also makes it possible to monitor the
„therapeutic climate‟; to control and measure the rehabilitative value of the community viewed
overall and within its sub-settings. It also allows for measurement of the progress of the patient‟s
rehabilitation during his stay in the community.
Since the construction and maintenance of the setting are based on the activity programmes
and respecting the rules, above all by the support workers, we have introduced sub-settings (some
with the patients and others with the support workers) to discuss, agree on, repeat, redefine, and
possibly modify rules, programmes and working methods. Contrary to what one might suppose,
the setting does not fragment or freeze relationships, but can facilitate communication and the
expression of experiences. For example rules such as that of reserving judgement, which operate
in the therapeutic and expressive groups, can reassure the participants against the fear of
retaliation, derision and negative judgements, and create a protected space where it is possible to
again get in contact with hidden and frightened parts of oneself.
In the Maieusis Community, due to the protection which the setting offers, there is a very high
level of patients participation (on average 90%) in all the activities in the programme, as well as
in the larger expressive and analytical groups 8of 25 people).
This model of the community as a setting which seems to have a typically paternal role
(imposing order and self-discipline) is in contrast to various pathological models.
The first model, typical of the mental asylum and some other structures, can be defined as
authoritarian and consists of an organization and roles of power which do not contribute towards
the rehabilitation of the patients, the development of their expressive, working, relational and
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introspective capacities, but instead works towards controlling them in the interests of the staff,
support workers administrators, family members and the public. This structure is mainly based on
prohibitive rules which, in our experience, tend to take on a meaning of „suggestions‟ 8in fact
negation does not exist in the unconscious). Thus the assistance workers find that they become the
protectors and enforcers of „rules‟ (identifying themselves with a negating and castrating super-
ego), with the effect of increasing the internal persecution of the patients.
A second pathological therapeutic community model arose as a reaction against the
authoritarianism of the hospital-type structure without any exact organization of activities or
definition of roles and power structures. Some communities with socio-therapeutic aims are based
on the presupposition that democracy and the absence of precise roles should help patients to
participate and learn to be responsible. Other communities suppose that „liberty‟ gives patients a
greater opportunity to express themselves and that in this way they might be helped to become
more aware of the dynamics of their problems, and that this awareness will spontaneously activate
a therapeutic process. Still other communities, based on intensive individual psychoanalysis, are
no more than an empty space where the patients stay between one session and the next.
These types of community, which do not have a well-defined setting, risk becoming anti-
therapeutic „pasture communities‟, where the patients pass the time, each one by himself,
wandering around as if browsing, looking for cigarettes or coffee. The apparent liberty does not
lead to spontaneity, responsibility or the expression of one‟s needs, because in psychotic patients
their needs are tenaciously denied and internally resisted by a negating super-ego. Instead it leads
to the expression of their negativity, and to the only „liberty‟ of being deluded and remaining
impotent and desperate. The ideology of liberty and democracy creates an alibi for the
irresponsibility of support workers and administrators, who can feel themselves authorized to
delegate the care of the patients to the „community‟, while simply leaving them on their own. The
lack of limits does not lead to a grater elaboration of the patient‟s internal fantasy, rather it leads to
a greater negation of the illness, and works in collusion with the tendency of the patient to deny
reality and the necessary comparisons and considerations which can lead to him becoming
conscious of his illusions.
A similar effect to the absence of the setting and the paternal function is produced by a
community which hypothetically is structured and defined but where in practice the patients do
not respect the rules and the programmes, and where in practice the patients do not respect the
rules and the programmes, and where the support workers, due to their indifference or
slovenliness, because of fear of the patients, in order to seem „good‟, or because of their
omnipotence or lack of self-discipline, do not respect the methods of work and are instead
„tolerant‟ and „permissive‟ with themselves rather than with the patients. Here the function of the
setting is planned, but it is denied and there is an attack on the role of the father and the principles
it represents: the principles of reality, responsibility, and respect for oneself and others.
In this anti-therapeutic community model the support workers oscillate between two opposing
attitudes. In on the worker is „permissive‟, allows exceptions to the rules and creates special cases
in order to satisfy the patient‟s „needs‟ (instead of helping him in every way to respect limits and
participate in the programmes). This leads to a collusion with the patient‟s tendency to overstep
boundaries, to be absent or passive, use spaces perversely and set up the support workers in
opposition to each other. It is basically collusive with the patient‟s sense of omnipotence and his
desire to change the world rather than himself.
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The second attitude, which follows the permissive attitude, is reproving, rigid and rule-bound. It
is an attitude which the assistance worker is forced into when the omnipotence and destructivity
of the patients start to control of the group. This oscillation in staff behaviour creates a
corresponding oscillation in the patient between an omnipotent position (with orgiastic fantasies
and the denial of dependence) and a subdued position characterized by fear of the punishment-
castration-exclusion from the community. In this phase the patients become obedient towards
an authority which is seen as persecutory and manipulative, incapable of clearly taking on
therapeutic power.
Being strict about respecting the rules without being super-egoic, being understanding of the
genuine needs and difficulties of the genuine needs and difficulties of the patient without being
tolerant and permissive of omnipotence and without being drawn into blackmail or succumbing to
the fear of destructiveness, are some of the fundamental aspects of the support worker‟s task..
They not only ensure the safety of the setting, which is as work instrument, but also the therapeutic
process of the patients who, when they do not keep to the rules, indulge in their tendency to deny
reality and increase their resistance to recognising their needs and their dependence on the staff.
In conclusion, the communities which do not allow for a programme of activities within precise
spatio-temporal and methodological limits are anti-therapeutic. This is even more true for those
falsely democratic and tolerant communities in which the support workers do not respect the
setting and, through fear of the patients or in order to show their good-heartedness, adopt a
permissive and collusive attitude towards transgressions thereby encouraging the omnipotence and
the destructiveness of the patients.
c) The community as a maternal environment
An environment is therapeutic if it allows patients to express an infantile and regressed part of
themselves, and if it allows them to gradually abandon the defences of the false adult self in order
to start to get in contact with a regressed but genuine self: a needy, frightened and aggressive part
of the personality which tries, although in an ambivalent way, to entrust itself to the care of the
assistance worker.
In fact a considerable part of the personality of the patient is divided and regressed to the first
years of his life due to the fact that he has introjected a maternal environment which „secretly‟
denies his existence or some rights which are necessary for his growth (the right to have security,
the right to have needs, the right to have respect and to have support, autonomy and sexuality). For
this reason the patient unconsciously continues to deny and hate his regressed ego, thus
maintaining the division.
When one speaks of regression it is necessary to distinguish between a benign regression,
during which one might say that the patient meets what we may call a „good mother‟ (which is
extremely therapeutic because it allows the patient to get in contact with his real self and abandon
the mechanisms of identification and the defence of his division), and a destructive or psychotic
regression, in which he experiences a „bad mother‟ and the hatred he feels for her, which pushes
him to divide and to fragment his inner world even more.
As long as there is a benign regression, during which the patient renounces his primary illusions
(autarchic, orgiastic, omnipotent and oedipal) while entrusting himself to the support worker, it is
necessary to create a therapeutic environment which is able to resist the hostile and self-destructive
negation continually indulged in by the patient, to take in and protect his regressed self, which is
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frightened and suffering (even when the pain is denied), and to answer to his need for maternal
care and attention (even when he attacks the bond with the support worker).
The support worker must be very careful to preserve the setting, the paternal function of the
community, since if destructive impulses are not contained and if omnipotence is met with
permissiveness rather than a recognition of the patient‟s real needs (as inexperienced workers are
often prone to do) then the house, even if it is attractive and has only a few patients, rapidly
deteriorates. It becomes a cold and persecutory asylum-like space in which the patients isolate
themselves, fleeing from relationships and seeking refuge in a pathological regression which can
result in one or more psychotic crises.
On the other hand it is not easy to preserve the setting if one is not able to create and maintain
an emotional bond with the patient, since it is exactly due to this relationship that he agrees to
respect the rules and participate constructively in the community programmes. The paternal and
the maternal functions of the community are thus complementary, contrary to what one might
suppose.
In the Maieusis community some elements of the setting, such as the expressive contact and –
therapy groups encourage the mother-child relationship between the support worker and the
patient and facilitate the transmission and acquisition of an adequate therapeutic culture. Even the
division of the community into little family-group, with small work-teams which ensure
therapeutic continuity, can offer the patients some protected and private relationship, in which the
primary introjected environment can be re –lived, modified and repaired. But the maternal role of
the community function above all by means of the support worker‟s activity.
This is a complex job which requires highly qualified professional (psychologist with experience
of personal therapy and training in the field) who must be able to deal with:
- Maternage, by which we mean maternal contact and care (looking after the patient‟s body and
appearance, his possessions, and his room)
- being able to listen to the patient and understand the primary language with which he often
expresses himself
- being able to answer (with actions as well as words)to the questions often concretely pyut
forward and at the same time denied by patients, while defending the patients from „internal
persecutors‟ (denying, disdainful, critical, de-valuating, derisive, reproachful, etc.)
- the ability to reinstate trust after the patient‟s attacks on the bond, betrayals of the relationship,
disregard and neglect of his needs and the denial of dependency.
The phase of therapeutic regression, which begins for the patient after a period of settling down
into the community, is a phase of the therapeutic process which can require a long time, many
„proofs of affection‟ and much effort by the assistance worker, before the patient decides to lower
his defences (risking the collapse of the constructed part of the personality and the emergence of a
destructive part) and decides to collaborate with the assistance worker. (Patients with personality
disturbances put up more resistance to regression than schizophrenic patients, for whom the
process of re-integration of the ego is slower.)
This image of the community as a place where there can be a therapeutic regression is in
contrast to two pathological models.
The first model is one which does not allow for the maternal function of the community. Some
people maintain that regression is never therapeutic, that a welcoming family-type environment
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should be avoided because it leads to the dependence of the patient, and that the community
should not be a happy island, because that would make the patient regress and become chronic.
Although it involves the important function of creating a greater sense of responsibility
towards the patient, the principles of egalitarianism and democracy if restricted to mere ideology
collude with the tendency of the patient to deny his illness, and with the assistance worker‟s
resistance to recognising the patient‟s regressive needs, and therefore also the importance of his
own parental role.
This way of thinking, which hides the fear of the bad mother and the patient‟s dependence upon
her, basically amounts to the proposal of a pathological community model in which the importance
of the maternal function is denied and in which the patients have their false conformist self
affirmed and their true regressed self remains ignored. They must be somewhat maniacal and
omnipotent, still maintaining a sadistic maternal super-ego against the weak part of themselves
and their companions (as if they were in army barracks). For this reason the regressions, although
ignored, will assert themselves anyway, will be only of a psychotic and self-destructive nature and
will reduce the assistance workers to a superegoic role of containment of destructivity and
repression of the needs of the regressed self.
A second pathological community model is that in which regression is ostentatiously allowed
(like in some small communities which are inspired by R.D. Laing), but there is a confusion
between different and opposing experiences in the belief that psychotic and destructive regressions
might, dialectically, have a therapeutic role. The leaders of these communities do not create
favourable environmental conditions in order to produce a benign regression. They do not see the
need for support workers with adequate training and experience who might be able to welcome
and accept the regressed self of the patient, and there is no preliminary work to contain the
patient‟s sense of omnipotence or to construct a bond and a feeling of trust. These theoreticians of
psychotic regression risk destroying the patient‟s internal world. Instead of meeting a good mother
he meets a bad mother and his own divided and persecutory hatred.
d) The community as training for life
Various different activities: expressive, working, relational and introspective, which are
necessary for the re-integration of the patient and the development of his capacities, must be
provided for in a therapeutic community. These activities give an opportunity for the patient to act,
express himself, come to terms with the support workers and his companions and in this way
discover a different image of himself, separate from the role of a person in treatment or a son.
Through the planned activities the patient can deal with his difficulties and the support worker can
support the inadequate functions of the patient‟s ego, first by carrying out his tasks for him, then
by sustaining him, although always in a decreasing measure, as he undergoes the process of
reintegration.
The rehabilitation of the patient is also helped by the fact that in the community there are not
only parental figures to by found, bat also brothers and sister, whit their own needs and rights,
towards whom one cannot put forwards claims. It is not wise to entrust the running of the house to
cooks, waiters or gardeners, because these jobs are necessary to make the patient responsible. The
problems of living together are discussed in assembly which does not claim to be „democratic‟ but
is simply a place where the patients meet to put forward and discuss proposals ( or more often
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request ) and where the assistance workers allow the patients to participate in order to
comprehend the meaning and importance of the rules and activities.
This, although very concisely described, is the nature of the rehabilitative treatment at the
Maieusis Community. We have however realized that this sort of treatment is insufficient when it is not
accompanied and integrated whit psychotherapy. The supporters of simple and straightforward
rehabilitative treatment wrongly assert that mental illness is simply the consequence of the lack of
adequate experiences; of a deficiency in the development of the functions of the ego. The truth is
that patient often possessed well developed abilities before his illness and the psychosis seems to
have destroyed them. In fact these abilities are mainly inhibited or forgotten for dynamic reasons,
in order to control anguish, pain and destructivity. In a moment of enthusiasm when he is
temporarily free from his fears, it often happens that the patient unexpectedly regains his abilities.
After axhieving this he once again feels violently assailed by his anguish and for this reason is
tempted to abandon the therapy or make serious damaging actions against himself. The
rehabilitative intervention would be sufficient if the forces which have determined the mental
illness were not still active in the patient‟s psyche. We have however observed, in our limited but
not insignificant experience, that schizophrenia is always accompanied by some form of self-
destructiveness.
Since actions, rather than words, reveal a person‟s intentions, even those which are unconscious, the
destructiveness of the patients cannot be other than the consequence of a repressed hatred, which is
always encountered sooner or later as analysis progresses: a hatred directed by the patient towards
himself and the people he loves and which pushes him to destroy his inner world. If this is the
situation, as we believe, then all the progress which the patient makes in the rehabilitative
activities will prove to be provisional and precarious if it is not accompanied and preceded by an
elaboration of the causes which are at the root of this hatred, if the patient does not manage to
accept himself and forgive, and if he is unable to be reparative instead of vengeful and self-punishing.
We believe that rehabilitation and psychotherapy have complementary and synergetic roles for
achieving mental health. Psychotherapy, which should work on the causes of the illness; on hatred
and the denial of one‟s rights, is impotent when dealing with the confusion, the negation, the
desperation and the intense needs of the patient who, since he is divided, often communicates by
only acting on his experiences. Rehabilitation, without attention and sensibility to the real
meanings of acts and words, and which does not consider the causes of the illness which are still
active in the patient, runs the risk of creating further fragmentation of the patient‟s ego and of
pushing him towards a passive adaptation to the environment.
Between psychotherapy and rehabilitation there should therefore be a relationship of the
following kind:
- the patient engages in the rehabilitative activities. He encounters a difficulty; a resistance
which can be manifested in various ways, often with destructive actings. The assistance
worker, if he is attentive towards his feelings also feels a countertransferational unease.
- The analytical elaboration of his underlying experiences, in a setting arranged for this purpose,
allows the patient to understand, and to a certain degree accept and regain his possession of the
divided, repressed and hated parts of himself.
- This sets free new energies of the patient who can in this way continue his rehabilitative
journey with less anguish than before.
- He encounters new difficulties which stimulate new elaborations.
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In the Maieusis Community this dialectic relationship between psychotherapy and
rehabilitation is most appropriately conducted in the small group setting. This is a weekly session
of the family-group (with the presence of the support workers and a supervising analyst) which
has various purposes, including the facilitation of the therapeutic-rehabilitative process of the
patient by means of elaborations of relational, working and expressive difficulties which they
encounter in the community during the week, and also by helping them to understand and take
back possession of their actions, which are often our patients‟ only way of communicating. The
dialogue between rehabilitation and psychotherapy can, in our experience, create a not necessarily
linear process of reintegration and effective reactivation of the patient.
This complementary process is well illustrated by means of two concrete examples.
- Lucio was quite adequate and sufficiently productive in carrying out his autonomous tasks and
working activities, but his problem was clearly seen in the expressive activities. He expressed
himself in a conventional and non-authentic manner. His creativity seemed to be blocked and he
was unable to use the expressive workshops productively. A deeper analysis revealed a dynamic
problem: he was afraid of not having any worth and of being mocked when he expressed himself.
By undertaking the work of analysis he began to get in contact with the symbiotic illusion, to
accept his limitations and willingly accept himself as he effectively was. By confronting the risk
of being derided and by directly expressing his undervalued and disdained part he found the way
to make his originality emerge and to develop a non-conformist identity, different from that of
his mother.
- Emanuela had left the TC and was living with other ex-residential patients in a house run by
them near the community. She suddenly found herself having difficulties in her work
apprenticeship, indulging in obsessive rituals, wandering around the community and finding
pretexts for arguing with people. Her rehabilitative process, regarding social reintegration,
seemed to be blocked, or indeed regressed, for what were evidently dynamic reasons. The
analysis of her motivations pointed out that, for her, starting work meant giving up her infantile
illusions and demands, as well as her illness and her unconscious plan of revenge against her
parents. By confronting a decisional crisis Emanuela began to abandon her unconscious demands
and deal with the fear of living autonomously.
In conclusion we can identify four more non-therapeutic community models.
- The first is a community model which does not allow for process of reintegration of the ego,
as in those communities which conduct activities with the principal aim of looking after the
patient, or of being places of play and entertainment .
- The second model has an exclusively rehabilitative function, in which the patient is “trained”
to be more effective in working activities, but since his repressed hatred is ignored he will not
be able to make peace with himself or develop his capacity for intimacy.
- The third model is exclusively therapeutic, in which rehabilitation and the patient‟s
verification of external reality are neglected, with the consequent risk of increasing his sense
of omnipotence and negation of reality.
- The fourth model is one in which psychotherapy and rehabilitation are divided, without a
sufficient relationship between them, for example, when there is the use of analysts from
outside the community, so that the patient can easily set up these two functions in opposition
to each other or keep them separate.
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e) The community as a space for re-planning
It can happen that the patient, during the process of reintegration of the ego, enters
spontaneously into a phase of re-planning and feels the desire to reconnect the wires of his life,
which have been cut by his illness, take up his studies or his job once again, acquire a greater
degree of autonomy, set up new emotional relationships and basically rebuild his life. Normally
however the beginning of this phase does not take place spontaneously but is determined by the
fact that in the therapeutic contract there is a time limit which both parties have agreed to adhere to.
A therapeutic programme worthy of the name must have a limit and be finite, in the same way
that the time and possibilities of everyone are finite. The deadline represents a limit to the
omnipotence of the patient and the assistance worker, who are therefore forced to examine the
results of their work and illusions. For this reason it always provokes an intensification of the
patient‟s symptoms and the tendency of the assistance workers to submit to „blackmail‟, thereby
prolonging the treatment and not adhering to the deadline. Dealing with these anxieties and the
underlying destructivity of the patients is however fundamental for their process of autonomy and
it can contribute to the acceleration and positive conclusion of the therapy.
With the approach of the time to leave the community it is necessary to increase the number of
contacts with the health authorities and with the patient‟s family in order to evaluate the patient‟s
residual capacities, verify his concrete opportunities and plan a gradual restitution of the mandate
which was given to the community. While the patient was previously encouraged to participate in
the life of the community, channelling his interest into the here and now, his attention now moves
to the future, beyond and outside the community and he must work to conceive and create the
living, emotional and occupational reintegration which is hoped for and is possible. In this way a
depressive phase begins, connected to the theme of separation, which leads to the confrontation
and elaboration of various themes.
These include:
- The confirmation of the often disappointing results obtained.
- The renunciation of the secondary advantages of the illness, such as the ability to blackmail,
apportion blame and demand reparations.
- The anger caused by broken illusions and the desire for revenge for being abandoned and
„betrayed‟.
- The worry that everything which has been built up with such great effort can be destroyed.
- The uncertainty about the future without the community-mother.
Reintegration involves either the return of the patient to his family or, more often, his
participation in an autonomously run household, rented by the patients or their families, near the
community. In both these cases, if the technical-economical conditions permit, it is a good idea
not to break off the therapeutic relationship, since in these way the patient would be deprived of
an important support, at the very time he finds himself having to deal with new problems
connected with his living space and working activity. A sudden cessation of the therapeutic
relationship, in such a difficult moment for him, would effectively amount to an abandonment
and a betrayal of his trust, with the risk of destroying the results achieved with such difficulty. It
is therefore necessary to achieve a smooth separation.
The programme of social reintegration at Maieusis (which also lasts a couple of years)
arranges for the participation (gradually reduced with time) of the patient in various activities,
partly conducted in the community and partly outside, which aim to sustain his process of
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autonomy and create new emotional and occupational reference points. Ex-patients are helped to
successfully rum their own homes, start driving a car or scooter again, attend a short professional
course, and to finish any studies they might have interrupted. Maieusis, with a group of concerned
parents, has promoted the setting up of a co-operative of services (cleaning, goods deliveries,
secretarial work, etc.) which aims to offer ex-patients occupational opportunities appropriate to
their effective possibilities. The patient has to learn to deal with his own „limit‟, become more
responsible for his own actions, and more aware of personal risk factors. The support worker‟s
task will be less prescriptive.
He will know how to wait maieutically* until the contradictions mature, he capacity for concern
and self-control develops in the patient and he finds, on his own, the solution to his practical and
psychological problems.
To the degree to which the depressive process leads to a gradual assumption of autonomy and
responsibility, the patient enters a reparative phase, in which the community becomes “the
mother” to be recognized, valued and restored. The frequenting and revisiting of the community
from “outside” facilitates the patient‟s possibility to see from “outside” and transcend the system
of relations previously lived from “within”. It also makes it possible to experience the feeling of
loss and recognise the value of the experience. The very fact of physical separation from the
community paradoxically makes it possible for him to introject it. In this way the organization,
the quality of relationships and the constructive finalities of the community become part, not only
of the patient‟s memories, but, in a deeper way, of this way of being and of forming relationships
with the others. Thus the experience of the community can contribute to the restructuring of the
character and stabilize of psychical equilibrium.
In conclusion we may state that those communities which do not arrange for and do not
work towards the patient‟s departure from the community and the conclusion of the therapeutic
process are non- therapeutic structures, in some way similar to mental-asylums. Communities
which do not sustain the patient in a concrete way, in his process of replanning and autonomy,
risks betraying his trust and reactivating his hatred towards himself and therefore his illness.
These communities, to a greater or lesser degree, deny the patient the possibility of the
constructively, separating himself from them and deny him the right to his autonomy and
reintegration into society, which is the final objective of our work.
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