INPATIENT PSYCHOTHERAPY OF SCHIZOPHRENIA IN THE DYNAMIC-PSYCHIATRY-HOSPITAL-MENTERSCHWAIGE (WITH A CASE-HISTORY)

The theoretical concept underlying the clinical work in the Dynamic Ps ychiatric Hospital Menterschwaige in Munich is that of Ammon's Berlin School of Dynamic Psychiatry. It has its roots in Freud's psychoanalys is, in the Ego psychology of Hartmann, Rapaport and Anna Freud and in the system-theoretical approach (v. Bertalanffy), which Ammon learned and practiced in the Menninger Foundation in the USA, where he helped introduce group psychotherapy and milieutherapy in the treatment of ps ychosis. In 1982, he replaced Freud's libido concept by the principle of social energy, i.e. the energy of interpersonal contact. Instead of the dogma of the unintelligible psychosis and of the psychotherapeuti c pessimism, dynamic psychiatry works with ''the paradigm of intelligi bility and therapeutic optimism'' (Ammon, Burbiel 1992). In this sense , healing is only possible for the therapist who believes in healing. In dynamic psychiatry, man is considered as a group being, shaped by t he unconscious dynamics of the groups in which he grows up. The pathol ogical dynamics in early childhood leads to the so-called archaical eg o diseases, such as the psychoses. Psychotic patients are individuals who have been abandoned emotionally in their early childhood. Their fa milies are characterized by reciprocal destructive aggression, rivalry and jealousy, which impede the contact necessary for healthy developm ent. Owing to the family's own fear of identity, the child is not allo wed to develop a constructive aggression. Later his aggression becomes deficient or destructive, i.e. directed against the surroundings or a gainst himself. The psychotic patient suffers particularly from an ove rwhelming anxiety, from which he flees in the world of schizophrenic d elusions. Thus, the psychotic symptoms fill the ''hole in the ego'' (A mmon 1972), i.e. the structural deficit in the core of personality. Th is human-structural understanding of psychosis makes it evident, that symptomatic treatment cannot result in a durable change. The aim of th e dynamic psychiatric psychosis therapy is therefore the development o f the constructive aspects of the personality, the repair of the struc tural deficit and the development of identity. In the dynamic psychiat ric hospital, each patient is given a specific therapeutic program. Th is consists of psychoanalytic individual and group therapy as well as non-verbal methods (milieu therapy, human-structural dance therapy, mu sic therapy, art therapy, theatre therapy and horse riding). All thera peutic levels are integrated in the supervision groups of the staff, i n the plenary group of the hospital and the case conferences. We will now describe the inpatient therapy of a psychotic patient: Mr. H., 30 years old, was admitted with the diagnosis of a hebephrenic psychosis, after longterm neuroleptic medication. He had been the only one of hi s family ''to fly out of the nest''. For five years he had lived isola ted and felt persecuted, he had repeatedly demolished his furniture. H e imagined his father to be ''gas'' and had destroyed the gas oven. In termittently, he was in a state of beatitude believing himself to be a n Indian or a bird in a forest. At such times, he would cool his head for many hours in the toilet. He had made several suicide attempts. M. H. was the younger of two brothers. He had been expected to be a girl . As a child, he had suffered from jealousy, since his brother was pre fered by the father. He described his mother as a tired, depressive wo man suffering from frequent heart pains. His father drank heavily, was irritable and aggressive. The climate at home was tense, with quarrel s and aggression. As positive influences he mentioned both grandmother s and later his music teachers. While he had felt an outsider in kinde rgarten and school, he found warmth and interest during the music less ons. He finished high school and studied music. We can characterize th e group dynamics of H.'s family as follows: H. grew up in an atmospher e of emotional abandonment, jealousy and destructive aggression. The d epressive mother attached the son to herself as a phantasized partner, causing him guilt feelings and preventing the contact between father and son, H. found in the hospital a male therapist interested in music . He experienced the latter as an emotionally open and sympathetic fat her, at the same time fearing homoerotic submission and dependency. He acted out these feelings by frequently alternating between symbiotic fusion and aggressive behaviour. A central aspect of the therapy consi sted in supporting his creative abilities in the music therapy, art th erapy and dance therapy. Through these interests he found contact to o ther patients in the milieu group, whom he had formerly avoided out of contact anxiety. The psychological tests at admission showed a psycho tic structure with pronounced destructive self-aggression, manifested by guilt feelings with sexual contents and by psychosomatic symptoms, as well as a deficient and destructive anxiety. Thinking was character ized by compulsion and depressive fixation, further by an extreme conc retistic disturbance. This made the schizophrenic symptoms understanda ble, in terms of concretistic-symbolic thinking, against the backgroun d of his life history: his anger with the emotionally distant father ( imagining the father as gas and destroying the oven), the resistance a gainst his homosexual anxieties (cooling his head in the toilet), the extreme abandonment (as an Indian in the forest) and the wish for sepa ration and freedom (symbolized by the feeling of being a bird flying f rom the nest). H. acted out his inability to separate from the hospita l which he experienced as the mother, and from the therapist-father, b y occasional uncontrolled attacks of rage. He demolished repeatedly th e toilet and threatened with suicide, thus making a psychiatric interv ention in a closed ward unavoidable. In order to relieve the symbiotic link to the therapist, it was decided in the case conference to conti nue therapy by the splitting method with two additional therapists. In the art therapy H. could give expression to his symbiotic wishes in c reative and abstract paintings showing uterus and embryo symbols. The separation phase of the inpatient therapy was problematic. H. persiste d in a negativistic attitude for a long time. Now his existential anxi ety behind the aggression became evident in the transference situation of the hospital. Finally, the patient felt understood in hi