British Journal of Psychotherapy

SUMMARY. During the course of a therapeutic intervention both the designated patient and the therapist(s) treating this person may emotionally decompensate and revert to a psychotic state of thinking and action. This paper discusses two such events and shows how they were ameliorated by a therapeutic milieu in which the people involved were initially overwhelmed by these psychotic regressions and were subsequently able to reconstitute themselves.

'Psychotic interventions' is an ambiguous term. But I use it deliberately. It can refer to therapeutic interventions done on behalf of individuals who are suffering or have previously suffered psychotic breakdowns. And it can refer to the actions of people, often designated as 'patients', who are going through the process of breaking down. Equally relevant, the term can point out the reaction of a human environment, the family or milieu that was supposed to be of help, but could not and did not. This is a container which can no longer contain terrible pain, confused thinking or angry outbursts. In other words I am considering the situation when the therapist or institution has collapsed, even if only for a temporary period. So this paper is about breakdowns on the part of both parties, those needing help and those giving it. And it is about the means by which these same two sides are able to reconstitute themselves.

I shall focus on events at the Arbours Crisis Centre, a unique facility in North London established in 1973. There three therapists and six individuals or families in acute distress live together in a large Victorian house. We call the people who seek help at the centre guests, both to describe their role in the house and to avoid problems of stigmatisation.

At the Centre there are three separate but inter-related and inter-relating therapeutic systems. These are the team, the group and the milieu. The team consists of a guest, a resident therapist (that is, one of the therapists who live at the Centre, the RT), a team leader (visiting psychotherapist, the TL), and perhaps an Arbours trainee. It meets three to five times a week.

The group consists of everyone who lives at the house, resident therapists and guests, and encompasses four formal house meetings per week.

The milieu is the Centre as an active therapeutic-environment. Perhaps active interpersonal environment is more correct as the milieu can also be non-therapeutic or even anti-therapeutic depending on, as we shall see, who is at the Centre and what is going on.
___________
Dr Berke is Director of the Arbours Crisis Centre. Address for correspondence: 5 Shepherd's Close, London N6 5AG.

It includes three resident therapists, six guests, nine team leaders and everyone else directly involved with the Centre. Various combinations of these therapists frequently meet with each other in order to help recognise, experience and tolerate the powerful emotional currents that flow through the house. Essentially we emphasise the role of the countertransference in coping with guests who are often verbally inarticulate.*

In order to illustrate the divers implications of 'psychotic interventions,' I will focus on the role of the milieu as the healing or damaging agent when working with a very disturbed and disturbing person. Specifically, I want to tell the story of 'Hamid,' a large man in his early twenties, whose family originally came from the Middle East. Hamid had a good intellect and did well at school. But as he approached university age, he began to bully his parents and younger sister and make rude sexual overtures to women both inside and outside his home.

Hamid was first admitted to hospital in his late teens because of severe aggressive outbursts. He seemed to seek out weak and vulnerable women and terrorise them. At his worse he appeared to be totally out of touch with reality and his behaviour was nearly uncontainable. He was referred to the Centre because hospitalisation did not help. After the usual medications and restraint, he remained the same incorrigible human being but with the added burden of being diagnosed as schizophrenic.

Hamid came to the Centre for a three month period, what we call a medium-length stay. At first he was very demanding and wildly abusive. He soaked up huge amounts of food, especially milk and sugar, while refusing to sit for any meals. His great delight was to make a huge mess in the kitchen. In the house he took on the role of overbearing potentate. All the women were his playthings or prey. In return they hated him. But when confronted he would deny what he had done and shout abuse. Generally he was extremely negative about the Centre and usually refused to go to house meetings. But he did attend his team meetings fairly regularly.

As his stay progressed he gradually calmed down and became more sociable. He surprised everyone with a keen sense of humour and a capacity for clear thinking. People began to see him as a bad boy rather than a mad boy. Certainly he tried everyone's patience to the limit so much so, that on a few occasions he was asked to go home for a day or two so the house could cool down.

Towards the end of his stay, Hamid showed sustained periods of sadness and could be intellectually impressive, engaging residents in long discussions about politics or philosophy. But these reflective periods were often interrupted by angry, impulsive, demanding outbursts. Hamid's accomplishments seemed in danger of being lost. He had reverted back to being chaotic and unbearable. Both the residents therapists and other guests were at their wits end, in outrage and despair. This was a turning point. Hamid had begun his 'leaving crisis.'

What do I mean by the expression 'leaving crisis?' In a previous paper (1987), I have explained that all guests pass through five distinct crises or stages while they are the Centre, regardless of their reasons for coming. These stages can be compared to five states of mind and greatly influence the feelings and actions of the guests while they are at the Centre. They are: Arriving, Settling-in, Settling-down, Leaving and Following- up*

* I have discussed these three therapeutic systems and how they operate in much greater detail in my paper, 'Conjoint Therapy within a Therapeutic Milieu: The Crisis Team' (1990).

The fourth stage, Leaving, invariably precipitates a fresh crisis because leaving necessarily arouses ambivalence, sadness and depressive feelings which may seem too strong to bear. To avoid the experience, many guests try to repeat their original breakdown. This was certainly the case with Hamid.

Everything seemed to blow up before his leaving date. Over the previous week he had become increasingly angry and abusive, and tempers were at boiling point among the therapists and other guests. Then, in mid week, the house itself seemed to respond in kind because the sinks suddenly blocked up with a black, foul-smelling liquid. The same morning we had our semi-annual medical inspection. There was a frantic rush to get the sinks unblocked which RTs accomplished just before the inspector, a very pleasant, elderly doctor, arrived. She had been to the Centre many times before and always enjoyed a quiet relaxed visit. As she had entered the kitchen for a cup of tea, Hamid suddenly brushed past her, screaming: 'Get out of the way you fucking old bag'. Everyone was appalled and one of the guests, 'Katie', started to cry. Even the RTs were shaking. But the doctor was not the least phased. She calmly commented, 'You know, it really is exciting to have a taste of real life!'

The inspection over, the RTs began to prepare for a reception in the evening. Every other month the Arbours sponsors a public lecture. Afterwards the lecturer and invited guests and therapists return to the Centre for refreshments and further discussion. So, having set out the food and drink in the front room, they specifically asked Hamid not to touch the stuff. Well, this was like a red flag to a bull. Upon getting back to the Centre after the lecture, they found that he had not only eaten a lot of the food but had been bullying the female guests.

Hamid saw the RTs and tried to be jolly, 'George, George, did you have a nice evening?' But they were furious. For them gobbling the food was the straw that broke the camel's back. Once again Hamid had broken all boundaries and they were left in complete chaos. All they wanted was for him to go, immediately.

They called his team leader and told him what had happened, that Hamid had been warned and had to go. The RTs feared that if they backed down and he did not leave, they would lose face and appear like Hamid's father, waffling and indecisive. Without further ado, the team leader concurred and suggested they call the father to come and collect him.

While they were about to carry this out, the RTs saw that I had just come back from the lecture and was about to sit down and talk with our visitors. Before I could do so, they literally pounced on me and insisted that I retreat with them to the rear consulting room to discuss him. So I excused myself and joined a group of very angry therapists.

*I have described these stages in my paper 'Arriving, Settling-in, Settling-down, Leaving and Following-up: Stages of Stay at the Arbours Centre' (1987).
The stages have a separate objective existence. This has been demonstrated by the fact that they occur in other different facilities as well as the Centre. Most notably, this paradigm has been confirmed by colleagues at the Mount Sinai Hospital in Toronto, Canada. In a paper on the intensive treatment of borderline patients they delineate stages which are practically identical to the ones 1 have described (Silver, Cardish & Glassman 1987). They describe these stages as follows: One - Assessment or the Honeymoon; two - Therapeutic Encirclement or Symptomatic; three - Therapeutic Engagement or Working Through; and four - Discharge-Liaison or Separation/Re-entry. Although, the Toronto group does not specify a follow-up stage, they do refer to the period 'following discharge' when patients like to return to the ward.

At this point I myself felt quite menaced for I could see that they would not take no for an answer.

'Hamid's been on the rampage. He's eaten the food and hit another guest. He's been warned several times. He has to go.'

Nervously,'Umm, I can see that you have tried and sentenced him. It seems that I'm to act as your executioner.'

In the meantime I realised no one was able to think. The situation was crazy. The RTs had collectively reverted to concrete or beta functioning.* Hamid had become their 'dreaded object.' And as far as they were concerned, their sanity, or at least peace of mind, depended on my getting rid of him.

While all this was happening, I remembered a similar incident that had happened several years before. The Norwegian government had referred a young woman to the Centre with a long history, I would say reputation, of autism and schizophrenia. She was a huge person and very aggressive. If she had lived a thousand years previously, she could easily have been a Viking raping and pillaging the North of England. In fact the referral was so unusual that we decided that the main point was simply to get her out of Norway. Anyway, 'Ingrid' had been at the Centre for several months and had just begun to form ties with the residents and settle down. One late afternoon I was called to the Centre by a nearly incoherent RT. 'Ingrid has thrown a chair at me for the last time. Either she goes or I go.'

In fact Ingrid had also been upset by someone's leaving. So she responded with violence, the one way she knew that would destroy her nascent feelings of sadness and depression. Really, what she did was not much different from previous episodes and I thought that once I came over and spoke with people, it would blow over. But it did not. The RT was adamant. Either Ingrid left or he did. In desperation I called my colleague, Dr Morty Schatzman, a co-founder of the Arbours, to come over and help me out. He too argued with the RT while Ingrid was storming around in the garden. All to no avail.

Several hours passed. The atmosphere remained explosive. Morty and I realised that neither gentle persuasion nor harsh facts would work. So we told the RT to stay and said we would take Ingrid to the emergency room of a nearby hospital, the Royal Free, for a shot of Largactil and, hopefully, a bed for the night. We didn't know and couldn't think about what else to do. By then we were tired and desperate and Ingrid was still storming. Off we went to the Royal Free. By the time we arrived, Ingrid had begun to calm down but we were extremely anxious, so much so that I was prepared to do something I rarely do, revert to tranquillisers and hospitalisation.

In the emergency room Ingrid insisted that I buy her endless cups of coffee and cigarettes. 'Anything to shut her up,' I mused, `This whole thing is nuts'. Finally the duty psychiatrist, a tiny, young Asian lady, came out for Ingrid. Quick as a wink I pounced on her, yelled a potted history and insisted on what I wanted her to do. She looked up and curtly remind me that she was the doctor in charge and would not decide anything till she had seen the patient.

*I refer to a reversion to psychotic thinking processes, and the use of what Wilfred Bion (1977) has termed 'beta elements.' These are indigestible bits, 'concrete sense impressions,' 'influential in acting out', 'thought objects', 'felt to be things in themselves as if to substitute such manipulation for words or ideas.'

Another half hour passed. Morty and I felt our agitation level rise to new heights. Then the doctor came out. I was just beginning to feel relieved that we could go home when I heard the hideous news. 'This person can go home. She doesn't need any medication.' 'What!' I roared. 'You can't do that. Look how upset and violent she is.'

While this was going on Ingrid came out and calmly sat on a chair smoking a cigarette. The doctor pointed out that she was perfectly calm and did not need treatment. I was dumbfounded. Suddenly a smile crossed my lips. The doctor and I had exchanged roles. I had called Ingrid a dangerous schizophrenic. The doctor saw her as a tired if slightly confused young woman. I was arguing for drugs; she was arguing against drugs. I wanted hospitalisation. She said it wasn't necessary. And not only had I changed roles with the doctor; I had exchanged roles with Ingrid. She was calm and quiet. I was raging like a maniac. The irony was not lost on Morty or myself. With that we began to calm down. Morty volunteered, 'listen, it's 2:30. I'll take Ingrid back to my house for the night. A good night's sleep will do us all good'. I readily concurred and that's how the crisis ended. In fact Ingrid did not go back to the Centre. She stayed as Morty's guest for a few days and then we found her a small flat of her own. She had never lived in her own flat before.

This whole episode flashed through my mind while I was trying to think how to handle Hamid and the RTs. One decision came quickly. Whatever was going to happen, I did not intend to become the knight in shining armour, the all powerful father who provided omnipotent solutions for his regressed children. But I also realised that far from playing the omnipotent father, the RT's had allowed me little room to manoeuvre. They clearly wanted me to become the impotent father who had to do their bidding. Surely, this was their sadistic revenge for my having inflicted 'Him' on them in the first place, and for having caused them so much psychic pain.

Angrily, 'Well, what are you going to do? We can't spend another night with Hamid in the state he's in.'
Again, I was taken aback by the extreme hostility but now I wanted to avoid appearing omnipotent or getting sucked in further.
'Well,' hanging my head for effect, 'I don't know. I don't know what to do.'
Really I was trying to buy time so that we could all begin to think.
'Let me see, you know we do have other options. I know we can get rid of him. Indeed that's one option. Let's see if there are any others. Right now I recall my friend Ross Speck.* He used to work with large families with one or more very disturbed members. He'd call them the designated patients. Could it be that is the case with Hamid? Could he be our designated patient, the carrier of all our craziness?'
Murmurs of annoyance.
'What Ross used to do when the large family group threatened to fragment, and expel a member, was to expand the group. Bring in more members, distant relatives, neighbours, even relative strangers. The point was to get people who could think to join the group. Maybe we can do that by carrying the discussion to the reception. Let's ask our visitors what they would do. Let's ask everyone else in the house too.'
More murmurs, but at least the proposal wasn't rejected out of hand.
'You know, we could also ask Hamid to join us. Perhaps he might come up something himself.'

* Ross Speck, together with his wife Joan Speck, worked for many years as family and network therapists in Philadelphia. See Family Networks (Speck & Attneave 1973).

At that moment, as if on cue, Hamid came into the back room and looked at me somewhat plaintively.
I said, 'Hamid, I feel very sad and upset about the situation.'(I actually did feel this way but I was also being deliberately vague.)
Hamid, who knew everyone in the house wanted him out, began to shake. He shot off to the kitchen for some milk. Then back in the room, and before anyone could comment, he went up to me and exclaimed, 'Don't worry. I'll go to bed.'
With that, he started up the stairs towards his room.
It was now 10:30, Hamid had been quite disarming and I thought it safe to suggest that we re-join the reception. I said it would help to think. The RTs agreed.
There were about 20 people there, our speaker, a few of his friends and colleagues, a few Arbours therapists, and the rest from the Crisis Centre. Everyone seemed to want to talk at once, 'What's happening, why weren't you here, where's Hamid?'
I explained what was going on, that we had a big problem, and asked everyone for their suggestions.
A few of the guests at the Centre went on the attack. Hamid had to go! 'Look he hit me today.' 'Why should we put up with that?'
Our lecturer, Dr T, gently inquired, 'Is he on drugs?'
Somewhat flippantly I retorted, 'Maybe we should all take some drugs, it could help us to calm down.'
The lecturer let a few guffaws pass and continued, 'You say you want him to leave. This is an unusual problem. Where I work we usually we try to get patients to stay, not to leave.'
He was quickly accosted by, Katie, a thin young woman who liked to cut her arms and face in order to reduce the tensions in herself. 'How can you say that. Don't you know what I've been through?' Another resident interjected that she hadn't been able to sleep for days because of Hamid, and the RTs, still angry, joined in.
Dr T continued. 'You know, we could all leave. Leave him alone in the house. But then, where would the RTs go?'
An animated discussion ensued. After a few more minutes I encouraged Dr T to add to his earlier remarks.
First, he asked a few questions. Why did Hamid come to-the Centre? How long for? Then Dr T presented his views about schizophrenia and schizophrenics as well as the treatments available, especially medication. People were not too interested and I could see they were shocked by all the medical psychiatric terms he deployed. Then he decided to tell a story. This was a story prefaced by the quip, 'You know, it's often easier to start again than to clean up a big mess.'
The story went: 'In Ireland there was a mother and two boys. -The boys went out one day to play by a bog. One fell in and was quickly pulled under. The other boy ran home to get his mother. She ran back to the bog and saw that her son was about to go under the quicksand. She rushed over and pushed his head under. Her other son was horrified. 'Mom, why did you do that?' Mom replied, 'Well, since I couldn't save him, I thought I might as well get it over with quick. Then I could start again.'
A stunned silence prevailed. Then Dr T added, 'In putting the boy back into the MUD, she was really putting him back into the MAD, into madness. Perhaps there was nothing more she could do. After all, she didn't have any drugs.'
This seemed to break the mood. I took a glass of wine and both guests and residents started to tuck into the food and drink. Everyone seemed to be talking at once. There was a jolly, almost hypomanic atmosphere.
Midnight came. Dr T and his friends said they had to go. While I escorted them to the door, another complete change of mood took place. The residents seemed to forget Hamid and focused on Dr T. He had become the whipping boy. Kate got angry with him for advocating drugs. Another accused him of being a tool of the establishment. And so on.
Midnight went. I had to struggle with myself to return to the meeting. I was dead tired and wanted to go home, especially since the Hamid issue was no longer pressing. But it had not been settled and I decided to stay as long as necessary to resolve things. In his talk Dr T had spoken about guilt and forgiveness. I hoped that the anger and guilt that previously had pervaded the house might be replaced by a mellowing of mood and feeling of forgiveness. Back at the meeting, I sniffed the atmosphere. The frenzied pressure to oust Hamid had gone. People were more uncertain about what to do.
Kate spoke about him, how he had called her a whore and slag. I queried whether this image might be connected to how he saw himself? An animated discussion about Hamid and sex ensued. How perverted his ideas all seemed. Was he really angry with his sister because she was good looking? Somehow the phrase, 'condom soup', slipped in. Condom soup?
'Sue,' a shy black girl who usually tried not to be noticed, piped up:
'At last some of the shit is out in the open. Anyway there were times when Hamid was OK with me.'
Another guest at the Centre, 'Ron', seemed to be falling asleep on a big pillow. But he was awake enough to remark that Hamid reminded him how nervous he felt at times. In fact, he was usually extremely depressed.
Suddenly, I realised that no-one was angry with Hamid. People were chatting away about other things. However, in order not to lose the opportunity to conclude 'the problem,' the point of the evening, I focused on Hamid again by asking,
'What do you think it feels like to be Hamid? What is it like to be so full of despair and fear and terror?' More talk. The meeting turned back to Hamid:
By now it was 1: 15. I said, 'I think our feelings about Hamid have softened a bit. But I don't think we should just let things hang. You know, when I came over tonight after the lecture, you seemed ready to throw him out. This doesn't seem to be the issue now, but let's go over what we can do, what the options are.'
Almost as if I were reading from a prepared list of possibilities, I started, one, two, three ... :
(1) We can get rid of him, immediately, forever.
(2) We can get rid of him in the morning after allowing him to stay overnight.
(3) We can ask him to leave for the night and come back tomorrow, as we have done before.
(4) We can let him stay, but set up a rota for people to stay up with him during the night.
(5) We all can stay up and cancel meetings for the next day.
(6) We can bring him back into the group, into the meeting right now.
(7) We can follow Dr T's advice and use medication. But who should take it and how much? Should Hamid take 100 mgm Largactil, or the whole group?
(8) We can all have a double Scotch.
At this point I interjected that when patients get agitated, their drug is Largactil but, when therapists get upset their drug is alcohol.
Many lively exchanges ensued.
Kate exclaimed: 'I'm against the use of all drugs.'
'OK, then I suggest we all take a glass of milk and honey. Let's give one to Hamid too. Then we can all go up and express our love for Hamid and hug him. I think Hamid's biggest problem is expressing and receiving affection. So, let's all give him some affection.'
Kate shouted as if speaking for the whole group, 'Joe, you give it to him first.'
I replied, 'OK, no problem, but before I do, let's all hold hands.'
In this way I tried to open a delicate subject, the open expression of affection in and by members of the group as a whole. After all, how could we direct it to Hamid if affection remained a block among everyone else?
A bit reluctantly, everyone stood up and shuffled around in order to form a circle and hold hands.
Suddenly Sonia, the RT, said, 'Let's all hug, holding hands is not enough.'
She then proceeded to hug everyone near her. I was amazed. Sonia is an affectionate but not a very huggy woman.
Sue found all this very difficult and half started to run away. Sensing that she was frightened and, because she was near me, I stopped her and gave her a mild hug. At the same time I could see that the whole group had begun to exchange hugs.
Meanwhile Ron had left for the kitchen. Like someone green with envy, he started to complain,
'Why is Hamid getting so much attention?'
George had gone to the kitchen to prepare the warm milk and honey. I might add that this is a brew which guests often take at night in place of sleeping pills. At my suggestion and, when not inappropriate, we may also add a tablespoon of fine brandy. A very important part of this ritual is that the guests see that a very special brandy has been added. In this way they- feel special too. The ensuing drink has been good-heartedly called, the 'Joe Berke special'.
Anyway, George made a point of giving Ron the milk and honey.
Back in the front room Kate volunteered to take a drink to Hamid.
But I proposed that we should ask Hamid to join the meeting. After all, all the hugs and warmth began after we had focused on helping Hamid to receive and express affection. He had sort of got lost, Ron's complaint notwithstanding, during all the recent exchanges of good will.
So Kate went to invite him down. A few minutes later she returned to the meeting to let us know that he had gone to bed.
It appeared that, while we were all very agitated, Hamid had calmed down and gone to sleep. Once again I was reminded of the story of Ingrid. While Morty and I had become increasingly agitated at the Royal Free emergency room, she had calmed down.
The group again asked me to take some milk and honey to Hamid. I agreed and went upstairs. In fact Hamid was not asleep, just lying quietly on his bed. Hamid took the drink and thanked me in a pleasant respectful way. He wasn't agitated. He wasn't psychotic.
By now it was 2:30 in the morning and it seemed that the immediate crisis had passed. No-one was suggesting that Hamid had to leave that night; in fact no-one was talking about his having to leave at all.
I was very tired and said good night to everyone.
In turn they thanked me and allowed me to leave without feeling anxious.
But, as I was later told, the evening continued.
After I left, Hamid came downstairs and joined the group of his own accord.
Sonia, who previously could not bear to touch him, suggested that they all hug. Hamid demurred but agreed to hold hands.
Ron shook Hamid's hands. Then the rest of the group greeted him and made a place for him.
All, including Hamid, helped to clean up. They continued to be huggy.
Hamid sported a huge smile. He was amused by the group's affection for him and said playfully: 'You lot are all mad and gay.'
This statement was not a challenge. Rather it was the harbinger of a calm and pleasant mood which pervaded the house. By the early morning everyone drifted off to bed.
It had been a good night. The group had reconstituted itself. The mad behaviour of Hamid as well as that of the therapists and other guests had ceased. Clearly, their psychotic anxieties, and thoughts, or rather lack of thinking, had receded too. All of the residents seemed much more able to regain and contain their own feelings.
A couple of days later Hamid had his leaving meal. This is a big event for the guest who is finishing his stay as well as the whole house. Extra food is prepared. Wine is served. Candles are lit. It is a real occasion. The celebration reflects work well done, on everyone's part. But completion leads to departure so that there is usually an air of sadness too. Notably, the Centre may feel flat and empty for days afterwards.
Hamid's leaving meal was by no means certain. He had never previously stayed for dinner at any time during his stay. Yet, on the day after the lecture, when asked whether he wanted to forget the meal and leave early, he replied, 'No way. I can't leave. It's my leaving meal tomorrow.' And indeed he helped plan the dinner and stayed almost to the end.
When he did leave, it was uneventful.

Discussion

Both with Hamid and Ingrid, as with other guests at the Centre, psychotic regressions in thinking and behaviour can brew up very quickly. This particularly happens when individuals who are unable to cope with sadness and depression are threatened by loss. Or to put it another way, catastrophic reactions occur when these same people are threatened by attachment, whether by making friends, or losing friends. Their capacity to hold depressive tensions is very poor and primitive defences against these tensions quickly unfold. I have used the word 'tensions' rather than anxieties. Really we are talking about a particular state of mind, one touched by sadness, loss and frustration and so on, but unable to contain these experiences. The ensuing chaos, or regressive madness, can not only engulf the person concerned but also everyone else in their immediate social field.
The result of our intervention with Hamid was that he formed an intense attachment to the Centre, both the guests and therapists. The actual process whereby this happened was painful and difficult. In retrospect many of his angry outbursts had to do with his trying to reject the relationships which he was trying to establish or had already established. His final blow-up, the fury and reversion to a prior state of extremely provocative behaviour, occurred when his stay at the Centre was coming to an end and he was devastated by feelings of loss.
The situation with Ingrid was different. She was tormented by the nascent process of forming friendships. This was something she had never previously been able to accomplish. Her prior attachments consisted of a primitive symbiotic relationship with her mother or with care-givers in institutionalised care. But I think we underestimated the attachments she did form at the Centre for, as I previously mentioned, she was clearly upset by another guest's leaving. And, as with Hamid, her ongoing tumult was an indication that little friendships were being established.
The massive outbursts of Hamid and Ingrid initially provoked similar responses on the part of the Centre. The resident therapists closest to them were overwhelmed by panic, rage and despair. These feelings were so powerful that they could no longer think or act as therapists. Like Hamid and Ingrid they just wanted to get rid of the threat, that is, the presence of Hamid and Ingrid experienced as frightening monsters. These concrete experiences were the counterpart of the 'dreaded objects 'which Hamid and Ingrid faced, sadness and depression. When the therapists called for help, it was not to resolve the problem but to execute the demons.
It would appear that we acted differently in these two instances. With Hamid we were able to keep him at the Centre and I was able to 'keep my cool.' But with Ingrid we could not manage this and Schatzman and I had to take her out of the Centre. Subsequently I felt overwhelmed by panic too and could not think.
But on closer consideration, the reactions of the Centre, and by that I include my own, were similar. In both interventions we acted to expand the group. For Ingrid this included Morty and the duty psychiatrist at the Royal Free Hospital. For Hamid this included Dr T, all the guests at the Centre and all the visitors that accompanied Dr T to the reception. Then we played for time, hoping that it would have an ameliorative effect, which it did. Perhaps most significantly in both interventions we were able to shift the focus of 'bad object' from the designated patient to another person.
The duty psychiatrist certainly became, for a brief period at least, my bad object, the person who refused to take my instructions and frustrated my needs. Dr T served the same function for Hamid by becoming a focus of anger for people at the Centre. They then neglected to be upset with their primary 'bad boy.'
In fact, Dr T is a highly skilled and very experienced dynamic practitioner who is very sympathetic towards the work of the Centre. He also favours psychotherapy as a basic treatment modality for psychotic patients. Certainly it was unfair to embroil him in an emotional maelstrom. He had just come back for a quiet drink. Nonetheless, when the episode blew up, it was very important for us to involve him and for him to become part of the treatment milieu. Dr T, as did the duty psychiatrist, served commendably in the role of surrogate ego, as well as surrogate demon, and in so doing, helped us all to think again.*
Essentially both disturbances were ameliorated by a therapeutic milieu that initially had been overwhelmed by chaotic currents, and was later able to reconstitute itself. The result was a strictly limited breakdown, contained by the willingness of the therapists involved to suffer, and by their capacity to ask for help and regain their thinking processes. This enabled the therapists as well as Hamid, Ingrid and all the guests at the Centre to discover and rediscover their sanity and humanity.

*In fact we used an array of auxiliary egos, myself to the RTs, Morty to me (and the RTs), the duty psychiatrist to Morty and myself, DrT to the Centre, in order to defuse the psychotic regressions into which we had been drawn.


ACKNOWLEDGEMENTS

I would like to express my appreciation to Sonia Whittle, Lois Elliott and George Pearce who were the resident therapists at the Arbours Centre when Hamid was there. I am grateful to them for all the mental pain they endured and for the resilience they demonstrated during the intervention with Hamid. I am also grateful for their helping me in the writing of this paper.

I would further like to thank my colleague, Dr Morton Schatzman, for his help with Ingrid.

Finally I would like to express my appreciation to Dr T for the valuable contribution that he made during the course of the evening.

References

Berke, J. (1987) Arriving, settling-in, settling-down, leaving and following-up: stages of stay at the Arbours Centre. In British Journal of Medical Psychology, 60, pp. 181-188.

Berke, J. (1990) Conjoint therapy within a therapeutic milieu: the Crisis Team. In International Journal of Therapeutic Communities, 11, pp. 237-248.

Bion, W.R. (1977) Learning from Experience. Reprinted in Seven Servants. Four Works of Wilfred R Bion. New York: Jason Aronson, p. 6.

Silver, D., Cardish R- & Glassman, E. (1987) Intensive treatment of characterologically difficult patients. In Psychiatric Clinic of North America, 10, pp. 219-245.

Speck, R.V. & Attneave, C.L. (1973) Family Networks. New York: Pantheon Books.

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