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 mid-1980s, 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 self-affirmation.'

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.

REFERENCES

Ainsworth, M. (1969). "Object relations, dependency and attachment: a theoretical review of the mother-infant relationship." CHILD DEVELOPMENT (CHICAGO IL) 40: 969-1025.

Bion, W. R. (1962). Learning From Experience. New York, Basic Books.

Eker, D. and B. Oner (1999). Attitudes toward Mental Illness among he General Public and Professionals, Social Representations and Change. The Image of Madness. J. Guimon, W. Fischer and N. Sartorius. Basel, Karger: 1-13.

Fink, P. J. (1996). Are psychiatrists replaceable? Controversies in Managed Mental Health Care. A. Lazarus. Washington, American Psychiatric Press: 3-16.

Fornari, F. (2000). Pour une psychanalyse des institutions. L'institution et les institutions.Etudes psychanalytiques. R. Kaës. Paris, Dunod: 95-130.

Gabbard, G. O. (1995). Psychodynamic Psychotherapies. Treatments of Psychiatric Disorders. G. O. Gabbard. Washington, American Psychiatric Press, Inc. 2.

Grinberg, L. (1962). "On a specific aspect of countertransference due to the patients projective identification." International Journal Of Psycho-Analysis 43: 436-440.

Guimon, J. (1985). "El equipo suficientemente bueno." Rev Asoc Esp Neuropsiquiatr 5: 501-505.

Kaës, R. (2000). Réalité psychique et souffrance dans les institutions. L'institution et les institutions.Etudes psychanalytiques. R. Kaës. Paris, Dunod: 1-47.

Layland, W. R. (1981). "In search of a loving father." International Journal Of Psycho-Analysis 62: 125-225.

Racamier, P. C. (1983). Le psychanalyste sans divan - la psychanalyse et les institutions de soins psychiatriques. Paris, Payot.

Roberts, V. Z. (1994). The self-assigned impossible task. The unconscious at work. A. Obholzer and V. Z. Roberts. New York, Routledge: 110-121.

Sacks, M. H. and W. T. Carpenter (1974). "The pseudo-therapeutic community: An examination of anti-therapeutic forces on psychiatric units." Hospital and Community Psychiatry 25: 315-318.

Winnicott, D. W. (1965). Ego distortion in terms of true and false self. The maturational Processes and the Facilitating environment. Londres, Hogarth Press.

Winnicott, D. W. (1971). Playing and Reality. Londres, Tavistock.