EXTRAMURAL CLINICAL MILIEU THERAPY IN THE THERAPEUTIC CONCEPTION OF DYNAMIC PSYCHIATRY

The paper is introduced by an outline of the therapeutic aims of dynam ic psychiatry and of the significance of the social energetic principl e in the treatment of severe archaic Ego-diseases. Extramural Clinical Milieu Therapy (ECMT) represents a widening of the therapeutic scope of clinical treatment by taking advantage of group dynamic and social energetic aspects outside the precincts of the hospital, in a foreign country. The clinical setting and the therapeutic network, including v erbal and non-verbal therapeutic methods, as well as the integrating f unction of the plenary group of the hospital, are described. The autho rs emphasize the central importance of the psychoanalytic milieu thera py in which the therapeutic situation is identical with the actual lif e situation of the patient. Thus, milieu therapeutic groups constitute >>timebound communities, within which all life manifestations of the patients are randered visible and assessable<<. Milieu therapy is espe cially indicated for those patients who, while having weak identities, are unable to gain insight upon their conflicts and instead act them out. Besides planning daily activities and structuring common time, pr eparing and shaping work on an own project constitutes the main aspect of milieu therapy. The latter should always include a spiritual dimen sion. The authors stress the specific pecularities of ECMT: transferri ng the therapeutic setting to a center outside the hospital, constant possibiltiy of communication with the hospital and the selection of pa tients according to precise indications, such as improvement ment of s eparation ability, loosening of transference on the hospital, stagnati on of the therapeutic process and improving reality coping. Not eligib le for ECMT are suicidal, socially dangerous patients, as well as pati ents with a pronounced acting out or runaway tendency. A comparison wi th >>journey or holiday therapies<< widely practised and described in the literature, evidentiates the lack of basic therapeutic conceptions and integration of these therapies in the context of hospital treatme nt, leading to mereley temporary symptom improvement. ECMT with patien ts of the dynamic psychiatric hospital Menterschwaige takes place in a Center at Paestum/South Italy with a rich historical and spiritual tr adition, tracable back to the 7th century B.C. The Center is surrounde d by an archeologically important site including the Greek temples of Paestum and consists of a central building complex in the middle of a landscape of terrace gardens. A short description of the Center is giv en by the authors. The fact that the patients themselves take over the planning of daily activities, such as preparing meals, shopping, wate ring the garden etc. is of therapeutic importance. The authors exempli fy their considerations by describing in detail the course and the gro up dynamics of a ECMT-group in October 1991. Eleven patients have been selected according to therapeutic indication criteria; the leadership consisted of one physician and two milieu therapists. The group had b een built up and prepared for the journey by regular sessions during s ix weeks under the supervision of the chief consiliarius of the hospit al. The daily structure in Paestum included, besides common meals, wor k on th milieu projects and group dynamic sessions aiming at communica ting and working through individual and group conflicts, also evening seminars held by the patients themselves about historical, political a nd cultural topics. Moreover, excursions took place to the island of C apri and the archeological site of Pompeji. The main project of the Oc tober ECMT was the renovation of a small village house. The considerab le amount of physical work was a particularly efficient therapeutic fa ctor for depressive patients, while the reality planning an execution of the work proved to be of importance mainly for schizophrenic reacti ng patients. Work on the project was closed up shortly before leaving Paestum, in a ceremonial act as part of the separation process. This p rocess was made conscious and elicited strong emotional and psychosoma tic reactions. The therapeutic integration of patients' experiences en sued by regular group sessions after return to the hospital for severa l weeks, whereby working through and integrating are indispensable the rapeutic factors making structural development possible. The closing p art of the paper deals with social energetic aspects of ECMT from the viewpoint of the patients themselves. Possibly efficient social energe tic factors in ECMT in distinction to millieu therapy inside the hospi tal are: clear time limits, narrow group feelings and contacts, higher personal responsibility, coping with reality in a foreign country and language, new possibilities of spiritual and cultural development of the patients and of overcoming the gap between work and leisure time.