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 pseudo-therapeutic 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 good-enough 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.