Author: Yulia Medynska, Ph.D. in Psychology, Associate Professor.
All the world’s a stage,
And all the men and women merely players,
Who have their exits and their entrances,
Who play their parts—W. Shakespeare. Jacques’s monologue from the comedy “As You Like It”
My presentation is based on my experience working in two psychoanalytically oriented psychiatric hospitals. These are two very unique psychotherapeutic institutions which, in our economic and socio-political conditions, seem more like a mirage, a sort of hallucination of those involved in the treatment process, rather than reality. This so-called “hallucinatory format” is linked not only to the uniqueness of this approach and its stark contrast to the reality of Ukrainian hospitals, but also to the massive regression in which patients constantly find themselves and which the staff constantly touches upon. This shared regression, like a stream of water, sometimes engulfs all participants, and sometimes recedes, revealing islands of the observing self. We hope that doctors and psychotherapists find themselves “above the water” more often than patients do. Ultimately, that is the essence of our work—to create this space for safe, free play, where various stories can unfold so that they can later be reflected upon, analyzed, “alphabetized” in V. Bion’s terminology, and returned to patients in a form they are now able to accept.
The interpersonal space of a psychotherapeutic inpatient setting is a network of free associations—group and individual—sometimes intertwined, flowing into one another, potentiating one another, and at other times—completely isolated from one another. It is a theater where many plays are performed simultaneously.
The level of symbolization varies in these performances—sometimes it is a very literal enactment of transference or intrapsychic conflicts. For example, a patient tries to break down the ward door because she wants to leave; the head of the ward holds her back, she breaks free, and struggles. And in this holding and confrontation, we see both violence and the sexualization of the relationship, as well as a provocation toward abuse—whether aggressive or sexual. At times, the interaction is more formal, “normative,” and more subtly and covertly contains unconscious motives. For example, a narcissistically affected patient, with a very traumatic childhood history, with depersonalization complaints that have troubled him since that very childhood, is cold and distant toward doctors and psychotherapists. He came to get rid of his detachment; he has already “cathected” the hospital; he has already given us a “sliver” of his libido, which is locked within himself, forming a sort of “depersonalization bubble.” By seeking help, he has already taken a step out of his narcissistic shell. But that is all in terms of establishing a relationship with the outside world. He unfolds a scene of narcissistic withdrawal in his interactions with us, demonstrating the futility of our efforts, our insignificance to him in his world “behind the glass.” And this is a scene that, with filigree precision, reproduces his avoidant attachment style and the difficulties in establishing contact with the helping professional.
Or the hypochondriac patient who is being treated for worms or an ulcer in a psychiatric hospital. And he seems to understand that they don’t treat worms here, but he smiles slyly when confronted with this. Periodically, he goes to doctors of other specialties, but always returns to the psychiatrist, playing a double game—taking antipsychotics for his worms… This drama unfolding in the hospital is a story about disrupted and undisturbed reality testing, about a relationship with objects where there is no trust whatsoever—and so these objects, unworthy of trust, must be deceived—asking them for help, but not revealing one’s true pain.
With the emergence of child psychoanalysis in the formats of Melanie Klein and Anna Freud, the method of free association took on new forms. It became clear that free associations could take the form not only of verbalized ideas, but also of acted-out scenes, game scenarios, and the characters within that game, and so on. This free associative play is constantly taking place in the inpatient setting—all participants in the process act out their own scenarios. To one another, they are the very same as toys in child analysis. The regression in which patients find themselves is a prerequisite for the regressive-syntonic enactment of relationship elements and fragments of scenarios.
What is very important: patients are in a state of regression not only during psychotherapy (which amounts to a few hours a week), but the entire time they are in the hospital (approximately 16 hours a day for 5 days a week = 90 hours). This is a key difference between inpatient psychotherapy and outpatient formats, where the patient, upon stepping out of the therapist’s office, finds themselves in a reality that demands an adult level of functioning—pragmatic, critical, responsible, effective, and burdened by current responsibilities and the consequences of their actions.
What does this mean for the inpatient setting? The processes unfolding during these 90 hours of regression each week resemble the constant presence of the unconscious in the structural model of the psyche. Hospital rules, daily routines, and hierarchical structures fulfill the function of the Superego. The treatment process itself—from the distribution and administration of medication to maintaining cleanliness in the wards—is the functioning of the Ego. The stories of patients unfolding in the inpatient setting are stories of the hospital’s unconscious, which is ever-present, while awareness and reflection occur only from time to time.
We can draw another parallel between inpatient psychoanalytically oriented psychotherapy and child psychoanalytic psychotherapy. In the work of child psychoanalyst Tessa Baradon, we find the following conceptualization of child psychoanalytic psychotherapy: “Psychodynamic therapy with parents and young children addresses the relationships between them in which there is a disruption or distortion of the process of establishing close bonds. A common characteristic of such relationships is the mother’s rejection of the child’s state and denial of the child’s needs, both in the child and in herself. The young child is drawn by the mother into a joint construction of defensive measures against the child’s needs for attachment, thereby reproducing patterns passed down from generation to generation. From a clinical perspective, the therapist serves as an observer of the relationship between mother and child and participates emotionally in it. Based on the behavioral and affective interactions of the “mother-child” pair, the therapist draws conclusions about the psychological models that emerge and the traditions of their coexistence. The therapist’s role is to symbolically represent, for both the parents and the child, their experience of coexistence. This is how an affective dialogue develops, one that incorporates emotional and mental structures that were previously played out procedurally.”
Inpatient psychotherapy is also a kind of “included observation” aimed at identifying implicit patterns, showing them to the patient, and helping them make sense of them, de-automatize them, and make them more conscious and manageable.
The medical staff performs the function of observation and conceptualization. They carry out this work in a collaborative format for several hours a week. This involves a large group setting and its discussion, as well as the actual psychotherapeutic staff (intervision or supervision of individual and group work, and the dynamics of the large psychotherapeutic group). Together, this amounts to 3 hours of collective reflection on the entire hospital theater that constantly unfolds around one or several patients and the staff.
There are various concepts regarding how the psychoanalytic space and the “objective” space—the space of academic medicine—intersect:
1. “Isolated psychoanalysis”—it does not address interpersonal relationships within the hospital setting, but only stories that take place outside its boundaries
2. “Bipolar system”—there is a conditional division into two planes—the therapeutic and the real. Only what occurs in the therapeutic
plane is studied 3. The integrative concept—where everything that happens to the patient in any plane of the hospital is viewed as a system of dispersed transference; accordingly, everything serves as material for exploration.
In my experience, first as a participant in the psychotherapeutic framework and later as a staff supervisor, there was a transition from the second to the third model. At the beginning, as I now realize, I had a somewhat flawed (inaccurate) understanding of the extent of patients’ regression in a psychotherapeutic inpatient setting. I assumed that regression occurs more or less throughout the course of individual or group psychotherapy. Now I see that this is not the case—regression is constant; the primal process permeates all interactions. Of course, one can choose not to think about this and not to see it. But then we find ourselves in a conventional hospital, not in a psychotherapeutic inpatient facility.
Regression takes place all the time; it constantly shapes the atmosphere of the hospital space, but what then happens during small-group or large-group work, or in individual psychotherapy? I call these segments of patients’ inpatient lives “chronological cross-sections” or “regression specimens”—by analogy with microbiological specimens studied under a microscope. Such a “slice” is like a drop of water from a puddle, taken to analyze the entire microflora and microfauna of that puddle; it is a drop of blood, taken to analyze the entire volume of blood in our body. Group or individual psychotherapy offers psychotherapists the opportunity to peer through a small porthole of a submarine into an underwater world that existed long before the submarine appeared and will continue to exist long after it disappears. This leads to the following thought: in inpatient psychotherapy, the periods of regression and non-regression, “up” and “down,” have switched places: regression is always present, while reflection occurs only occasionally—and precisely during the time we classically associate with regressive functioning.
It is interesting to take a closer look at the therapeutic stance of doctors and staff. As I mentioned at the beginning, all participants in the therapeutic process are drawn into group regression. This is a technical prerequisite for the emergence of projective identifications—if we do not allow it to occur, if we do not allow the processes of transference and countertransference to unfold, then the psychoanalytic process itself will not take place, and we will deprive ourselves of important tools. The normal cycle of psychotherapeutic contact with patients involves oscillating between regressively reliving experiences and the staff’s subsequent reflection on them and communication back to the patients. That is the ideal scenario. In reality, however, the staff itself sometimes finds itself in such a whirlwind of events when it comes to reactions or enactments within the staff. And then the secondary process—the reflection on what is happening with patients—becomes merely an imitation of the secondary process. In reality, our free associations about patients, our emotionally charged conceptualizations, may be nothing more than our own regressive reactions to the inpatient dynamics.
A brief summary. Regression in inpatient psychotherapy is constant; it affects everyone—both patients and staff. This is the fundamental difference between inpatient and outpatient psychotherapy. And it has fundamental consequences:
1. Group or individual psychotherapy is not about moments of regression, but rather, on the contrary, moments of coming to one’s senses, of making sense of regressive phenomena.
2. The work of the psychotherapeutic staff is an attempt to break free from this constant regression. The staff’s goal is to maintain a healthy therapeutic split within themselves—the ability to interact and engage in this vast free-associative theater while also stepping back to analyze what has occurred.
3. The concept most relevant to what takes place in a psychiatric-psychotherapeutic inpatient setting is the idea of “integrative psychoanalysis”—where everything becomes material for analytical understanding, ranging from a patient’s conversation with a nurse to, so to speak, “classical” free association in individual psychotherapy.
4. The associative process within the inpatient setting is structured like the associative process in child psychoanalysis—it can be thought of as a free play, where everyone becomes a “toy” for one another, and the plots of the enacted scenes have the same significance as a child’s play in child psychoanalysis.
Thus, the psychotherapeutic inpatient setting is a grand psychoanalytic game of free associations and interactions. If we try to see it this way—even in some small way—we are in a psychoanalytic clinic; if we ignore it, we are in a classical psychiatric hospital. Everyone chooses their own path.