Doors in the mind: Reflections of a resident therapist on
the metaphor of doors in a therapeutic community

Kate Hardwicke

Kate Hardwicke is a Resident Therapist at the Arbours Crisis Centre,
41 Weston Park, London N8 9SY

Introduction

The Crisis Centre is a facility of the Arbours Association. The Centre provides intense personal and psychotherapeutic support for individuals and families in severe emotional distress. The Crisis Centre was founded in 1973 and is located in a large Edwardian house in North London. What is particular to the Centre is that three resident therapists live there. It is their home together with six people in need of help (whom we call guests to avoid issues of stigmatisation).

I have lived and worked at the Crisis Centre as a resident therapist for two and a half years. Having completed a six-month placement as a student at the Centre, I wanted to have the opportunity of being part of the living experience of this unique house. My husband moved into the Centre with me. Although initially he was not working as a resident therapist, our being a couple stirred up many mixed emotions for the guests and ourselves, as I hope to illustrate in one of the vignettes in this paper.

Many people helped by the Centre have suffered from long-standing, severe emotional difficulties. Stays at the Centre range in length, from one week to six months, depending on the assessment at the initial consultation. Alongside those of us who live-in is the wider group; the team leaders, a psychiatrist, a nurse Manager, an art therapist, a movement therapist, the clinical assistant, financial administrator and students on placement.

Each guest has a team. The team consists of a team leader (psychoanalytic psychotherapist), a resident therapist and sometimes a student on placement. The team meets with the guests three times a week for fifty-minute sessions. Along with the team meetings, guests are expected to join four house meetings a week (these meetings consist of the resident therapists and the guests), and a movement and art therapy session once a week.

Physical and emotional holding

The Crisis Centre is a house with many doors. Symbolically, the doors in the house delineate an internal world of compartments. These compartments are ways in which aspects of experience are split and kept separate, or locked up. For many of the guests that come to the Crisis Centre, compartmentalising is a way of managing their internal world, a system that protects them from feelings that are feared to be too overwhelming. Coming to a house where doors are not locked can feel threatening to the psychotic part that wants to keep the mind rigidly compartmentalised. Living at the Crisis Centre, for both guests and resident therapists, is a kind of journey, travelling through house and mind in terms of opening and closing doors.

In the psychotic world, the mind doors may be closed, partially or altogether, and in this paper I'd like to explore how the therapists at the Centre try to keep an open door and an open mind.

I want to think about how guests arrive at the Crisis Centre, especially those who come to us directly from hospital. In my experience those with a history of hospital admissions find the transition to the Centre particularly hard. It seems that hospital provides an environment where safety is a constraint either through the use of medication or through the setting itself. People who come from hospital are used to a physical holding. In a way, they come to the Crisis Centre to find out whether they can make the transition into a more symbolic holding experience, and whether they can begin to use psychotherapy. This doesn't mean that suddenly they arrive at the Centre and can automatically adapt to a way of thinking. Arriving at the Centre is frightening, an unknown. Rules and negotiating these rules are part of the milieu and not just prescribed. This is often felt to be confusing and alarming when there may be expectations that both internally and externally we will solve difficulties and take the horrible feelings away, as if the resources are only to be found in the therapists. But just as the therapists are fantasised as the magical source of change, they are also experienced as useless, or brutal intruders. The work is to help the guests begin to think with us symbolically and to find out what emotional holding means, just as a door becomes a gateway to another place or to another self. Whilst hospital provides a safe setting it colludes with the psychotic disturbance; that is, the psychotic part that doesn't want to think but experiences disturbance in a concrete way. This is not to lose sight of the overwhelming feelings that can be terrifying and where the most physically containing thing for the individual might be medication or some kind of environmental constraints.

Apart from the difficulties of arriving at a new door, there is the trauma of leaving an institution where doors might be shut to emotions but provide something like a sense of being safe inside a structure. In hospital, doors are clearly marked. Wards label different hierarchies of disturbance. Hospital provides a sanctuary for the psychotic part, to be inside in order to get the madness out, free from the constraints of thinking. Although the Crisis Centre is not a place without doors, where anything goes, new guests aren't quite sure what to make of the process of negotiating boundaries for themselves and with the resident therapists. In this sense, compared to hospital, the Centre can feel like a neglectful or cruel place, with its accessibly open front door, where all doors externally and internally lead to others and where thinking might connect what happens in between these doors. Although some guests might hold the view that hospital has ensnared them in order to keep them alive, the Crisis Centre is a place that allows them in their minds to die by not keeping them shut in. This is why there is often a pressure from guests that the resident therapists behave like nurses and that the Centre actively co-operate with the need to be re- hospitalised. Hospital, with its secured setting is seen as a good parent, keeping the guest physically safe. The Crisis Centre, on the other hand, is denigrated by the psychotic part of the guest, which is threatened by emotional holding through relationships and thinking.
This helps to describe the inflammatory experience of relationships to the psychotic way of thinking. As therapists, we are invited by the guests not to think but to bear anxiety and to act from anxiety that the guest cannot bear. A guest arrives clinging to a familiar and particular way of dealing with internal splits. For those who communicate through acting out or projective identification, talking and exploring these splits makes little sense when the idea of getting together internally and externally is the very anxiety they are avoiding. Hospital may be less threatening to the psychotic internal world and could be described as its concretisation. Attempting to understand can be experienced as devastating and is actively guarded against. Changing this experience may be a slow and indigestible process, as words and food get evacuated and we are provoked into non-thinking by reactive interactions, so reflecting an internal split between all good and all bad experience.
When we think about doors we think about being let in. We think about moving from one room to another. We think about closing or locking the door for security. Doors can have other meanings too, like being shut out and excluded. Being shut in for punishment; there are trap doors and revolving doors. In childhood there are often fantasies about opening a door and not knowing what monsters hide or lurk behind them. We can also think of the slamming of doors, particularly for frightened guests, who in anger will slam the door and cut out all nutritional contact with the rest of the group. When you open or shut a door as a therapist, what does it mean for the guest or patient? Does opening the door to thinking mean strengthening of the well-mind or does it mean a kind of emotional rape? Does closing the door for sessions mean safeguarding the space for thinking, or does it mean that guests are locked in with the abuser in the room? Living in a house with many doors and fantasies, where doors lead to different spaces of privacy, of safety, of isolation, of exclusion, of group meetings, the complexity of newness and familiarity that these doors conjure up is always present, from arrival to leaving.
I would like to illustrate these points with the following clinical vignettes. The first example I've called 'Inside', as it describes how a guest found ways of showing concretely her need to get inside. The second example is called 'Outside', and shows how a guest could only show her distress by sabotaging her life and throwing herself out. The third vignette, 'Inside outside', describes a guest's struggle to arrive, stay and move on to one of the Arbours' communities.

Inside

Mary, a woman in her thirties, came to the Centre for a short stay of four weeks during a holiday break. Mary had previously moved into one of the Arbours' communities for a short while, following a long hospitalisation. She had been readmitted to hospital because of the extent of cutting to her arms. This had been her coping strategy for some years. Her recent cutting was, she said, precipitated by her feelings of disappointment with another resident in the community. This revealed something of her difficulty with negotiating intimacy and distance in relationships. When we first met Mary for a consultation at the Centre, she told us that she had been sexually abused by her mother. Her parents separated and remarried on several occasions. Although it was the summer break and we would have fewer resources with the team leaders away, we felt that a short stay at the Centre would provide a holding space for her to think about what was happening and about whether the community could become a safe enough place for her to return to.
Mary would wake me and my husband nightly by coming into our room, standing by the bed and shouting my name. Although I did manage to encourage her to knock on the door, her nightly visits, demands, and my acceptance of them came to be dreaded by both me and my husband. We felt abused by her. In addition, this just seemed to reinforce the view that doors did not exist in her mind and the safety of them in the house was felt to be only of exclusion, of getting shut out. Mary had been shut out. Boundaries did not make sense except as an excluding parental barrier and had to be disregarded. Her voices were telling her to kill herself at these times. I found I wished her dead too. It was as if her way of getting inside me and between myself and my husband was the only way she could feel alive. It was often my husband who would be aware of her presence in the room before me. These nightly intrusions became fraught with difficulties between us, of how to make sense to Mary about whose space was whose, without just resorting to keeping the door concretely locked.
I was not able to think. I felt a captive of her voices and undermined by the threat that she would die if I were not to be a concrete presence for her. As if I were an omnipotent being who could take these feelings away. Whilst she slept as a matter of course from a sleepless night, I dutifully attended her morning team meetings, exhausted, alone and unable to think. I wondered what shutting the door would mean. Would shutting the door also be a way of opening the door? How would it be possible to find safety without doors representing barriers? But Mary helped me to think about what it means to need to get inside and to keep the mind door shut. How was I to keep a thinking door open under pressure from the psychotic part to slam the door? I had to find a way to protect myself without shutting the mind door.
It was as if the parental room was a concrete representation of her need to be with the mother. At the same time getting inside was a way of turning me into a zombie as it seemed she had become through her experience of abuse. The more she entered the bedroom, the less capable I was of opening the mind door, which is how she kept the psychotic part safely locked up. Her safety depended upon showing me in a very concrete way what it was like to feel like her; invaded and intruded upon.
Mary was offered a further long stay at the Crisis Centre but funding was not agreed. Although she did resume her place at the Community, her stay broke down soon after she returned. She was readmitted to hospital.

Outside

Caroline came to the Crisis Centre for a four week assessment. She had had many hospital admissions for severe self-harming and suicide attempts. She experienced terrifying nightmares that hospital staff had needed to awaken her from. When Caroline was very young, her sister reported to the police sexual abuse but she was not believed. This meant her sister grew away from her and eventually trained as a nurse. As her life began to come together she developed heart disease and died. Caroline berated herself for not having backed her sister's statement to the police.
Caroline is a thirty-five year old mother of three. She seemed to relive the horrible abusive events of her and her sister's childhood through nightmares. The nightmares turned into literal experiences. Her relationships with others, including her children, were extremely destructive. Her children, among others, were witnesses to vicious and brutal attacks on herself. Living with her as resident therapists, became a nightmare of terror. It was difficult for both her and the resident therapists to distinguish what was a nightmare and what was waking life.
It was as if the therapists' part in this construction was to participate in a Russian roulette. On the one hand, she was afraid that if we were not a constant psychical presence we were not guarding her from herself. On the other, to be a physical presence, was felt to be an intrusion into a threatened, fragile mind. For Caroline, encouraging thinking was further evidence of neglect and passive participation in her deadly world. She became enraged by not being physically restrained or prevented from leaving the Centre and for not being woken from her fitful nightmares. One of our dilemmas had to do with a carte blanche invitation to walk into her room whenever we heard her making noises in order to wake her. But to think about this ambivalent message of demanding physical contact meant revealing a need to be held and abused at the same time. Thinking about this ambivalent need inflamed the psychotic her into preferring death over such humiliation. We had to keep in mind her wish to leave and her wish to stay at the Centre. However, it was a struggle to do this as there was also a her who wanted to prove that we would reject her and close our door.
Although we have had other guests with similar patterns of behaviour, Caroline's internal condition was a dire one. Her dilemma was either that she did not speak out and was left with the 'nightmare' of terrible abuse and the sadistic indifference of people watching without doing anything; or that she put herself in the hands of a terrible nurse who one minute smiles and the next gives her a lethal overdose. This murderous nurse is in competition with the professionals who are treating her, trying to prove them wrong. Any attachment is considered as lethal and further measures are taken to stop it. The problem is dealt with by killing the patient. When she speaks out, this is experienced as a betrayal and subsequently this is why her stay broke down.
When Caroline withdrew into a dissociated frame of mind, shouting out to herself, we would try to speak to her to bring her back. One time she ran for the front door. One of the resident therapists tried to barricade the door while I tried to hold her to stop her from leaving. Eventually she came back into the room but quickly returned to this dissociated state and repeated her attempt to leave. As we responded physically again by trying to prevent her from going, we realised the madness in our actions. What were we trying to do in preventing her from leaving the house? Something was going on where we were pulled into a re-enactment of forcing her to stay and at the same time responding to what could be her need to be forced to stay.
The dilemma within Caroline was also reflected in whether she could allow herself to stay and have relationships with us. How could she do this without the attachment turning into an abusive relationship? What the psychotic part of Caroline was proposing was that the only way to keep her safe was by imposing restraint, a wish that would have to come from the outside. This would mean responding to her in a preventative way or to leave her completely, in the murderer's hands, as it were. Both are equally collusive and abusive responses but responses that the resident therapists felt a pull to act into and that needed to be thought about.
Unfortunately, Caroline's stay ended prematurely. The part of her who wanted 'out' could not let us help her. We were not able to keep her safe from the murderer inside. Caroline returned to hospital.

Inside outside

Julie arrived at the Centre for a long stay. She came with suicidal wishes and a complex early history that included sexual abuse, over-involvement with mother, and a secretive and violent family. She had self-harmed as a child.
Early in her stay, she attempted to kill herself. This was her only suicide attempt at the Centre and served to communicate in the only way she knew, the seriousness of her distress and capacity to harm herself. Julie demonstrated how terrifying it was to be in a house where she would not be continuously under the watchful eye of hospital staff. Any kind of separation was experienced as devastating, as if this was evidence of her own self-hatred and view that she was evil. Throughout her stay, holiday periods were very traumatic for her. This was an important focus for the team work and gradually Julie began to nurture a sense of her own identity and autonomy.
During one of her team leader's breaks, Julie barricaded herself in her room experiencing me, her resident therapist, as neglectful and hostile. This is when the door became something else. Barricading her door was a way of showing that she didn't need us as well as a way of letting us know how frightened she was. Contact could only be tolerated with the door between us, as if opening the door would mean violence, or violation.
I would often feel saturated and consumed by her. She seemed to need to merge with me. This would show itself in different ways. Sometimes with her wearing clothes almost identical to mine. Sometimes in her thinking and belief that I had the same thoughts, or at least knew her thoughts. At times she also experienced me as someone who was actually attacking her from the inside. This was often how I would feel. How was I to keep the door open to her without getting filled up with denigration and hopelessness? Whilst Julie desperately wanted to get inside, she wanted to destroy the inside that reminded her of the abuse and her quest for intimacy. Julie in her time at the Centre struggled with her relationships as I struggled in my relationship with her. There were times when I felt consumed by hatred for her and needed a lot of help to stay in touch with the compassion that often seemed so tenuous. What I learnt from Julie was how undifferentiated her experience of love and hate was. At times I felt like I was the only person in the group who experienced Julie as intrusive and vengeful. Through these periods of isolation I came to understand what it was like to be governed by split feelings inside and out. As Julie approached the end of her stay, leaving the Centre became a feature of the painfulness of separation. It was hard for her to hold on to the relationships and the work without at the same time holding onto the view that she was being shut out forever and would have to shut us out. Julie did move on to one of the Arbours communities and continued to see the team leader, her psychotherapist, from the Centre.

Discussion

How at the Crisis Centre do we work through and think about the experience of both the internal and external threat of an open house? For most coming to the centre, the experience of safety is an unknown. People arrive in a state of mind where symbolisation is not possible. To hold someone in mind is experienced as a failure to hold physically. To this way of thinking, human contact means physical contact and safety means external physical security.
How do guests then find ways of obtaining that experience symbolically? It is almost as if the experience of being interned is the only one that comes close to keeping the psychotic part intact and a way of feeling parented that is both a familiar pattern and an anonymous experience. Relationships can still be avoided whilst the guest is physically secured in hospital.
I have attempted to show in my vignettes, how these guests have organised a mind-structure of compartments. Hence, keeping the psychotic part safe in a walled up room, protected from the possibility of a door or window opening into an adjoining chamber of thoughts and feelings. These guests concretely project their mental compartments into physical experiences in the house. Some guests might stand rigid at a door, unable to go in or out and will stay in between rooms, reflecting an internal conflict. Some might feel unable to enter certain rooms, or feel terrified of being in a room and will keep themselves out and excluded, becoming increasingly isolated and separate. This might be because a room is associated with people occupying the room for team meetings and will be a constant physical presence at constant times in the week. But the presence of a team also means relationships evolving, which the psychotic part experiences as a kind of forcing entry and is therefore under threat of exposure and humiliation. The conflict here could be a dilemma for the psychotic part, where on the one hand for, it to be preserved it cannot be understood and to be understood means its destruction. This internal conflict is mirrored by guests' showing concretely their distress physically and in physical spaces. We are constantly faced with a need to help the guests to find words that can connect to this internal conflict, that thinking about these positions doesn't mean having to guard one from the other, that the connection between these positions is about relating.
Arriving at the Centre from hospital means guests are literally thrown into a situation where they have to make the transition from a physically secure environment to a mentally safe one. As the task of making the move to the symbolic from the concrete is a difficult one, we have to be particularly aware and find a way to help them through this transition. Though this takes time, the Crisis Centre stay often enables people to go on to individual psychoanalytic therapy and to move on to a therapeutic community.

The identities of guests in this paper have been disguised.

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