---------------Windsor conference papers------------------
Bridging the gap
Julia Saltiel and Lois Elliott

ABSTRACT. The gap that people face when moving into a therapeutic community or moving out creates a great deal of anguish and anxiety, resulting in ambivalent feelings which can jeopardise the person's achievements and hopes and lead on to destructive behaviour. The Arbours Crisis Centre Support Programme was set up specifically to bridge these gaps; to create, in Winnicott's terms a transitional object or space through which these transitional gaps can be negotiated. The work of the Programme is described and discussed in the light of two specific cases.

The gap referred to in the title of this paper is the transitional gap that people face when moving into a therapeutic community or moving out. It is about the need to 'bridge the gap' between hospital/institution/family/or isolation, and moving into the new environment of the therapeutic community. As Yalom, in his book The Theory and Practice of Group Psychotherapy, states: "Entry into any established culture - be it new living situation, work, school, hospital, and so on - produces anxiety and, as extensive research indicates, demands orientation and support." (Yalom, 1985 p.328). This paper is also about 'bridging the gap' between leaving the safety and security of a therapeutic community and moving to independent living. Again in the words of Yalom all patients experience anxiety and depression following departure from a group; a period of mourning is an inevitable part of the termination process." (Yalom, 1985).
These transitional 'gaps' create a great deal of anguish and anxiety, resulting in ambivalent feelings which, if left unattended, can jeopardise the person's achievements and hopes and lead on to destructive behaviour. The Arbours Crisis Centre Support Programme was set up eight years ago specifically to bridge these gaps, to offer group psychotherapeutic support to people in the transitional stages of moving into or leaving the Arbours Crisis Centre and therapeutic communities.

The Arbours and the Support Programme

The Arbours, a registered charity, was founded in 1970 in order to assist people in emotional distress and offer alternatives to traditional psychiatric treatment. The Arbours Crisis Centre was established in 1973 to provide immediate and intensive psychotherapeutic support for individuals, couples or families threatened by sudden mental and social breakdown. The three long-stay therapeutic communities provide a supportive therapeutic environment where individuals in emotional distress can live for a number of years.
The Support Programme is a group which is based in the community and combines group psychotherapy and art therapy. It provides two sessions per week: one group psychotherapy session and one art therapy session. It is a small, intensive, open group with up to eight members, including the two facilitators one of whom is an art therapist and the other a psychotherapist.
This model of working, combining art therapy and group psychotherapy in one group, was developed from the work and experience of the Arbours Crisis Centre. The different trainings of the art therapist and the psychotherapist provide a deeper understanding of the work and a broader spectrum through which it can be understood and fed back to group members. The different perspectives not only complement each other but also expand our capacity for insight, understanding and containment. The Arbours Crisis Centre and therapeutic communities all provide group psychotherapy and art therapy. It is therefore a safe and familiar model of working for those joining the Support Programme after leaving the Crisis Centre or community and becomes an introduction to the way of working for those waiting to go to the Crisis Centre or community, so that they don't feel completely thrown in at the deep end once they move in.
There is no fixed period of membership in the group; how long a person stays will depend on the gap to be bridged. People have been members of the Support Programme for a few weeks, during the transitional stage of leaving the therapeutic community; a few months, whilst a vacancy in the therapeutic community became available, or, as in Deborah's case, for a period of a year whilst funding was pursued.

Deborah

Deborah had completed a six month stay at the Arbours Crisis Centre and was expecting to move straight into one of the communities. The day before she was due to leave, however, she received word that the funding had not been agreed by the local authority. It was therefore suggested that she join the Support Programme until the situation was resolved, which was anticipated to be a matter of a few weeks. It eventually took one year. Deborah returned home to live with her mother and began attending the Support Programme whilst the debate about funding got under way*.
In Deborah's case the debate was three-fold. It involved a dispute as to whether it was health or local authority responsibility to fund a therapeutic community place; there was a disagreement between the psychiatrist and the social worker as to the appropriateness of the treatment plan (the psychiatrist in favour of the therapeutic community, the social worker against); and an insistence that all local resources be tried before an extra-contractual referral could be made. What became evident to us as Deborah continued on the Support Programme was how these external conflicts reflected her own internal conflicts.
Deborah was the elder of two children. Her sister is two years younger, and was born at the same time as their father left the family home. Their mother found it increasingly difficult to cope on her own with two small children and became depressed. Deborah became the husband and the father, looking after both her mother and sister very efficiently and effectively - and also, at times, her father during the numerous but short periods of reconciliation that the parents had. It was only as Deborah herself approached adulthood and independence that the effects of her early experience became more evident. She developed difficulties in regard to food, either not eating or bingeing. She had periods of depression, during which she was at times suicidal and made several attempts on her life. Other than these things she remained her usual quiet, caring self.
Deborah was in her mid twenties when she came to the Arbours Crisis Centre. She had had periods in hospital and periods of independent living in hostels, but each had always ended in her returning to live alone with her mother (her sister had since moved away). Through her work at the Crisis Centre she decided to move onto a therapeutic community rather than to return home at the end of her stay. It was at this point that funding was withdrawn.
When Deborah first began attending the Support Programme we were struck by how calmly she appeared to have accepted her sudden change in circumstances. She was neither angry nor disappointed, seeming to accept the situation with infinite patience and understanding of the complexities that the bureaucracy involved entailed. As the situation continued over a period of weeks with no sign of its resolution, Deborah began to talk about not going to a therapeutic community but remaining in her present living situation and "just getting on with things". This alerted us to the fact that the 'gap' had allowed Deborah's ambivalent feelings to come to the fore.
We began to understand that her present situation mirrored her earlier life circumstances in which neither of her parents took responsibility for her, as neither

the health authority or local authority would accept responsibility for her now. That Deborah's family, and Deborah herself, had difficulty in acknowledging the seriousness of her emotional distress - attributing her depression and suicide attempts to adolescence or a "phase that she was going through" - was reflected in the disagreement between the psychiatrist and the social worker as to the appropriate treatment, and the suggestion of local resources such as living alone in her own flat and help to find a job. We were able to understand these issues as a projection of Deborah's own wish to deny the extent and seriousness of her emotional difficulties. With this awareness we could then help her to bridge the gap between the Deborah who knew that she needed help and the Deborah who despised that needy, dependent, baby part of herself.
Over the year that she was in the Support Programme these issues surfaced time and again, in particular when another group member left to pursue a more independent lifestyle and Deborah would feel that she 'shouldn't' need further help. However, alongside of this, Deborah herself began to be more vocal about her need for help and her wish to go to a therapeutic community, rather than passively agreeing to whatever was suggested by whoever she was with. In the Support Programme we watched as her paintings developed from being watercolour shades that were pretty but felt very empty, to her being able to use stronger colours, and eventually black and red.
Finally, funding for a community was agreed; and as she prepared to join the community these issues resurfaced, this time in terms of having gained so much from the Support Programme itself. Deborah had worked very hard and gained a lot from her time on the Support Programme, and it would have been very flattering to believe that we were the ones who had provided the help that she had needed. There had been no further suicide attempts or extreme eating behaviour. However, we had not lost sight of the very depressed and distressed part of Deborah, and knew that all we had done was to help her to hold on, to 'bridge the gap' until she could get the long-term help that she needed. She became very angry with us for not letting go of our awareness of this, but also angry with us for letting her go. We talked with her about this and she managed to continue to come to the group. Her last painting in the group stood out, as it was in a very different style to most of her paintings. It was an abstract painting with a solid background and several distinct, differently-shaped and coloured boxes, not imposing on each other, but able to be in the same space together.
We decided that Deborah should have an overlap period of two weeks during which she would move into the community and begin her individual therapy. This was somewhat unusual, as we usually recommend that a person finish one therapeutic intervention before embarking on another. In Deborah's case, however, we felt it to be essential. We were aware that if there was even the smallest gap she could easily slip through; that her strongly ambivalent feelings could still jeopardise her hard-won hopes and achievements. Deborah did go to an Arbours therapeutic community, and is still there at the time of writing, having joined the community eight months ago.

Susan is a young woman in her early twenties who attended the Support Programme for four weeks. She had been living in one of the Arbours therapeutic communities for four years and attended the group to help with the transition into independent living. Susan had only previously known children's homes, foster care, and bed and breakfast accommodation. The therapeutic community was her first experience of a consistent and containing environment. In the community she had been a committed member of the art therapy group where one of us had been working with her for four years. She had used the group to its limit, pushing all the boundaries. In it she found a safe and solid space where she could push, but be held and be helped to eventually hold those boundaries herself.
We are going to describe her first and last paintings, which illustrate very powerfully her struggle to hold onto a good internal object (the community) and take it with her, rather then spit it out because the loss of it felt too devastating and persecuting.
Susan likes to work with a square piece of paper. In the first painting she poured lots of different colours onto the paper. She then scraped off the excess paint onto her palette. It was now full of a shitty-coloured mixture, which she discarded. She then covered the whole area with translucent gold, using a spatula. This brightened the surface. She took off the masking tape, which created a border around the edge of the paper. Throughout the painting she was completely absorbed, but now she sat back, looking doubtful. This was one of those moments of uncertainty when she lost any good feeling about the group. We felt at that moment she could not bear her picture. She became very angry with herself, and started to paint the border in deep red. Time ran out and the picture was unfinished, with its incomplete border.
She said about her work that she had done a similar painting in the community and that it had worked very well. We felt that the border represented the gap made by leaving the community and that she was filled with anger and anxiety. Taking off the masking tape had unmasked how shitty she felt and how she had been glossing over her feelings about leaving the community. While living in the community these feelings, including her denigrations and idealisations, would have been thought about and contained within the therapeutic framework. The question now for her in her first meeting with us was: could she and could we contain them? We talked about what leaving the community meant to her. She denied having any difficult feelings about leaving and said that she was relieved to be out of the community and had no wish to return. We felt that this was her attempt not to feel her anxiety and depression, and that at that moment she was not going to mourn her departure from the community.
In Susan's last painting she worked very quickly, mixing pinks and purples and then making splodges all over her paper. She then painted a light violet colour all over the work, rubbing the brush hard onto the paper, trying to break down the splodges. The paper was now a dense violet. She then sat back, looking dissatisfied. We felt she wanted us to intervene and probe her as to how she felt, but we decided not to: we did not want to disturb the process for her. If we had intervened we would have colluded with her desire to not get in touch with her feelings. Susan then started to scrape a jagged-shaped star out of the centre. The star exposed what was underneath, the coloured splodges. She then started using a dark purple to outline the shape of the star.
Time had run out, but she continued to finish outlining the edge of the star. We realised that she could not tolerate an unfinished piece of work. Time had run out for her on the programme and, like her painting, she would not be coming back to finish the work with us. Susan wanted to have the perfect ending - for things to be whole -which was symbolised by painting the perfect picture with everything neatly in its place. But the star shape reminded us of a shattered pane of glass. We interpreted this as to how she experienced being in her last group; that it cut into her and exposed her feelings of loss and sadness.
The star is a pretty shape, but it did not take more than a glance to see its jagged edges. Susan wanted to be a star, the good one, the one who would produce a nice complete picture in the last group. But the shattered edges showed us that in her attempt not to experience the loss of the community she also could not feel her attachment to either us or the group. She had to smash her association of the group as representing the community and Arbours. We were then able to make the link that these paintings represented her anxiety and fear of loss in leaving the community and the Support Programme.

Conclusion

Winnicott says of transitional phenomena: "This intermediate area of experience, unchallenged in respect of its belonging to inner or external (shared) reality, constitutes the greater part of the infant's experience and throughout life is retained in the intense experiencing that belongs to the arts and to religion and to imaginative living, and to creative scientific work." (Winnicott, 1988, p.465) The Support Programme bridged the transitional gap for Deborah and has become part of her experience, which hopefully she can retain whilst she continues to build a more imaginative life for herself. In the same way the Support Programme can help in the transition from therapeutic community to independent living.
For both Deborah and Susan so much would have been lost had they not been attending the Support Programme. For Deborah the possibilities for her future emotional development were in jeopardy and for Susan her first experience of a containing environment was in danger of being lost. For both women the level of anxiety and anguish during their transitional gaps was so great that there was a pressure to resort to old coping mechanisms. By offering the space where the links could be made and thought about both of these women were able to recognise the dynamics of what was happening. They could make choices about which direction to go in.

Therapeutic Communities (1998), Vol. 19 No. 4 © The Authors