Patterns of Repetition and Change in a Psychoanalytically Informed Therapeutic Environment for Severely Disturbed Patients

Abstract: Factors in the environment and therapeutic relationship which facilitate, as well as those which obstruct the process of psychic change were investigated in patients with psychoses or severe personality disorders, starting from a preliminary theoretical model for psychoanalytically oriented treatment. Ten patients consecutively admitted to a Swedish therapeutic community, Bikupan, and who completed the treatment, as well as their 9 therapists were studied in detail during, and up to five years after the treatment. Explorative and supportive factors in the ward atmosphere were investigated. In a programmatic study, the Bikupan project was placed in the context of the current methodological debate. Some of the basic assumptions of current psychotherapy research were critically examined. The chosen research strategy included multiple qualitative and quantitative methods. The starting point was the experiences and subjective pictures of the involved parties, as well as a systematic comparison of their views. A research strategy for systematic case studies was developed, based on independent judges and consensus analysis of narratives.The ward atmosphere at Bikupan was compared with two other Swedish therapeutic communities with a cognate orientation. The conclusion was that a beneficial psychotherapeutic environment requires consistency in the applied treatment model, including an organisation and setting which tallies with the explicit treatment philosophy, well mirrored in the patients' perceptions. In the psychotherapy studies, more concordance at termination between the patient's and the therapist's view of their collaboration was preceded by working through of some of the patient's pivotal difficulties, as they appeared in the therapeutic relationship. More discordance at termination was connected with severe obstacles to the therapeutic task through the whole treatment period. Seven of the 10 cases were consistent with the hypothesis about the significance of therapeutic work with intra-therapeutic separations for the longitudinal outcome. Absence of signs of mourning seemed to be connected with less emotional and functional improvement. Besides the therapist's contribution in the middle phase, the patients' different ways of dealing with the trauma of termination probably have decisive impact on long-term courses. The investigation showed inconsistencies in the applied treatment model, which stimulated attachment and regression, but neglected the actualised feelings and relationship patterns. The process of repetition and change continued in the post-treatment phase and influenced the longitudinal outcome.