Christian Gaedt -1-Psychodynamic Orienteated Psychotherapy in People with Learning Disability

Psychodynamic Orientated Psychotherapy in People with Learning Disabilty1

IntroductionIn the past, hardly any attention has been paid to psychiatric disturbances in mentally retarded children in Germany. Normally such disturbances were interpreted as an expression of organic brain disorder or as a result of misrouted adjustment processes. More precise diagnostic differentiations and the development of appropriate therapeutic approaches were impeded by the promblematic relationship between educationalists and psychiatrists. For a long time the educationalists fought to attain responsibility for caring for mentally retarded children; and as long as these children were residing in psychiatric institutions, educationalists were more interested in distancing themselves off from psychiatry than in forming a new basis for cooperation. In addition, they widely accepted the opinion that the medical institutions themselves and their forms of treatment were the primary cause for the development or aggravation of disturbances in mentally retarded children. In those pedagogic facilities in which a therapetic approach was present at all, it was oriented toward behavior therapy. Under these circumstances there was hardly a chance for a psychodynamic approach to be implemented in a systematic manner nor to be evaluated in regard to effectivity. Therapists who were interested in achieving scientifically validated positive outcomes as fast as possible were afraid of the complexity of psychoanalytical theory and practice. In addition, it is always difficult and risky for the psychodynamically-oriented therapist to integrate the caregivers in the therapeutic process, whereas the plausible rules of behavior therapy give the caregivers a feeling of competency and enable them to distance themselves from the problems which are often very depressing. Finally the psychoanalytic training institutes have no interest in the problems of mentally handicapped persons whatsoever. Consequently, many questions concerning the applicability of psychoanalytical theory remain untouched and unanswered. So the therapist has to deal notonly with the usual mistrust, but with doubters within his own ranks. Evidently things seem to be similar in other countries (Lewis & MacLean, 1982; Ruth, 1990; Sinason, 1990) and so experiences are lacking in this area, we are confronted with more unresolved issues than with reliable facts. So, there are only sporadic publications on this topic. A good survey of these experiences one can find in Matson and Barrett (1982) and in Dosen et al. (1990). They are all the more encouraging. Stimulated by these experiences a diagnostic-therapeutic concept was developed in Neuerkerode, which is primarily based on a psychodynamic approach. This concept is the subject of the following report.

Description of the facilityThe therapeutic concept that will be described in this paper has been developed during

1 English version of „Psychoanalytisch interaktionelle Psychotherapie bei psychisch kranken Menschen miz geistiger Behinderung“, arbeitshefte kinderpsychoanalyse, 14, 63-85, 1994

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the past fifteen years in Neuerkerode. For a better understanding, the structure of this facility will be outlined below. It does not readily fit into the usual classification scheme and is not comparable to the typical, large psychiatric hospital. It is more like a small community. Neuerkerode offers a wide spectrum of different accomodations for about 750 mentally retarded persons. In addition, 70 residents live in two villages and two cities nearby. Most of them live in a group setting, some inhabit apartments alone or with others. They are cared for by staff, who are specially trained. Their training includes educational as well as medical aspects and teaches them capabilities for dealing with the daily needs. In Germany they are called "Heilerziehungshelfer" (one-year-training) or "Heilerziehungspfleger" (three-years-training). Neuerkerode regards itself as a denominational educational institution since it was founde about 125 years ago. It has an independent, but fully integrated medical center at its disposal offering various medical services for the residents.

In the last 15 years the percentage of residents with behavioral problems and with dual diagnosis has increased to about 35 percent. To cope with this, a psychiatric ward accommodating nine patients and psychiatric services were installed. These services consist of ten psychologists and one psychiatrist working in two teams, and are accessible only for residents of the facility (including those not living in Neuerkerode). It is based on a client service model and is backed up by five occupational therapists, two special vocational therapists and one speech therapist. The cooperation with the medical team is extensive.

The admission of children has become very rare because better alternatives are available. Today, only 20 residents live here who are younger than 18. All of them are severely handicapped or are extremely mentally disturbed. In the last ten years about ninety children have been attended to by the psychiatric teams. The organization of these services and a description of the clientele is published elsewhere (Gaedt, 1987; 1990). Thus I will restrict myself to the therapeutic concept in the following.

Basic assumptions :

Developmental deficits as a pathogenetic conceptFreud's conflict-oriented conception has been proven insufficient to explain the most frequently encountered and most challenging psychopathology associated with mental retardation. Here, ego-psychology including object relations theory and psychoanalytic developmental psychology have opened up fascinating new ways of understanding (Blanck & Blanck, 1974 and 1979; Jacobson, 1964 Spitz, 1965; Mahler, Pine & Bergman, 1975). The psychic structures and functions enabling the child to exist as an individual within social relationships are built up in a process of interaction with early significant objects. Hereditary and constitutional deficits, other organic factors, and pathological social environmental influences as well, result in an inhibition or distortion of this developmental process. The specifity of causes seems to be less important than the phase of their influence.

Even under favorable conditions, a handicapped child will hardly have a chance to develop normally. This is because, primarily due to organic damage, the child/environment interaction is severely impaired. Thus the relationship between parents

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and their handicapped infant differs in a critical aspect from the one they have with their non-handicapped children: parent-child interaction is dominated by the parents themselves and not by the infant (see references provided by Levitas and Gilson, 1988). Furthermore, this interaction pattern is reinforced by staff of the agencies providing therapy and special education, and leaves its mark in every stage of development. Weaknesses in personality structure result from this distorted interaction process which Levitas and Gilson have termed "secondary psychosocial deficit". In children, the most important characteristics of this "secondary psychosial deficit" are an atypical sense of self ("mediated self"), a primitive superego and an omnipotent ego- ideal. Due to thir immature personality structure, these children often show behavior which could be interpreted in terms of psychopathological symptomatology, although it would not be correct to speak of a psychiatric disorder in the narrow sense of the word. For instance, such children over-react to experiences of loss, they are more vulnerable to threats to self-esteem, and they require more emotional support when demands are made on them.

These structural weaknesses are a result of "normal" development under the condition of mental retardation. The severe psychiatric disturbances which we observe in mentally handicapped children develop when early interaction processes are marked, for example, by indifference, neglect, abuse, or isolation. In most cases, the diversity of such disorders makes it difficult to fit them into available classification systems. Usually, however, the more important objective is to describe the persisting developmental deficit in order to plan a strategy for treatment. This must include relevant concepts in assessing disorders of ego-weakness (i.e. defective ego functions, ineffective defense system), primitive object relations, archaic superego structures, and an inadequate self-concept. These deficits are seen by many authors as the basis of adjustment problems and emotional disorders in mentally retarded children (Robinson & Robinson, 1976; Balthazar & Stevens, 1975; Sternlicht, 1976; Levitas and Gilson, 1988; Ruth 1990).

Deficits of ego functionsEgo functions are instruments of adaptation, integrating internal needs with the demands of the outer world and the superego (Hartmann, 1958). They are related, for example, to memory, speech, control of motor impulses, perception, reality testing, synthesis, and judgement. Children with defective ego functioning may show hyperactivity and strange forms of gait or posture. They may have difficulties in inhibiting stimuli, thus they may become flooded. They may not be able to distinguish internal stimuli from external perceptions. Reality testing may become difficult. They may be unable to associate aggressive impulses with their origin and to control them. And, to add a further example, they may not be able to tolerate tension.

Immature defense mechanismsAnother set of functions to achieve adaptation are defense mechanisms. Various types of defense mechanisms protect the individual against anxiety caused by internal or external sources of danger and are especially important to ward off the painful awareness of an unconscious wish or fear. They characterize specific developmental phases. In the course of development, early, immature forms are replaced by more effective ones. If the defense system continues to be primitive, anxiety cannot be bound effectively, and may intrude easily and massively into consciousness causing disruptive behavior. On the other hand, immature defenses often involve the social environment in an intensive and

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dramatic way; this is especially true for splitting. In addition to splitting, other primitive defenses are denial, primary identification, introjection, projection and incorporation.

Primitive object relationsThe development of ego functions and defense mechanisms is embedded in the process of differentiation of the self and its relation to the world of objects. In order to understand the inner world of a mentally retarded child with mental disorders the child psychiatrist has to find an empathic access to these different developmental phases, which are described, for example, by Blanck and Blanck (1979), Berman (1979) or Trad (1986). The process of separation and individuation starts when the infant exists in symbiotic union with the mother and is successfully terminated when psychic autonomy is achieved. The self can then be experienced as a distinct coherent entity.

Every stage of development has its specific developmental task to be mastered. If the infant fails to accomplish it, the process of development will not come to a total standstill, but in the life course specific needs and conflicts having their origin in the disturbed developmental phase will impede social adaptation on a more mature level and may provoke typical clinical symptoms. For instance, frequently an incomplete separation of self and nonself can be found. Then, a primitive fear of merging or aggressive attempts to establish an effective boundary resulting from such an insecure self-object border may be observed. Self-mutilation such as head banging or self-biting can be interpreted in this way. On the other hand, a continued desire for symbiosis, resulting in an undifferentiated fusion with the external world and in parasitic relationships may be observed as well.

Primitive superego structuresDue to ego-weakness and the persistence of primitive object relations, problems with the development of the superego will occur. A mature superego is one of the prerequisites for autonomous existence. A well-functioning superego will set reasonable goals and standards. It will not only have the function of a "controlling court" but will also be a source of self esteem, making the child less dependent on the object for narcissistic replenishment (Chetic, 1979). If the development of the superego is impaired, the children will not have effective internal controls and expect stability and controls from their objects. This may be one reason for marked dependency and clinging behavior frequently observed. Furthermore, under the influence of harshness and violence in early childhood, precursors of the superego tend to remain externalized; these children will then experience the outside world as hostile and frightening, reflecting the emotional quality of their early object relations. As a result of this experience the children usually have a high level of anxiety and tend to deny the realistic world, remaining attached to their narcissistic fantasy world.

Immature transference phenomenaThe differentiation of object relations is not only a structural process, it also has an affective aspect. The affective experience of early relationships, especially during traumatic phases, influences the emerging self and object representations. Thus the infant acquires affective patterns to judge and classify the outer world which correspond to these early experiences. These preshaped affective expectations combined with corresponding behavioral tendencies will be effective in later life. So, if the child sees the

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"devouring witch mother" in his/her caregiver he/she will react with panic or with aggression strictly denying the real characteristics of the object. If another child experiences "the omnipotent, all-giving mother" he/she may appear to be overly demanding and will be frustrated easily. This phenomenon is similar to what is known as "transference", but it is more archaic because of the primitive nature of the object relations. Blanck and Blanck (1979) call it "object replication".

Pathological identityIn the normal course of development these archaic, combined affective and behavioral patterns have a transitory character. However, they are the basis for what is called identity. Identity refers to an enduring schema for self-recognition and self-realization (Berman, 1979; Erikson, 1956). The development of these schematas is an ongoing lifelong process. The grown-up individual deploys an ensemble of well-differentiated, adaptable schematas and uses them to organize a stable and satisfying individual world as far as possible. Different needs are adapted to these schematas in a very individual way, and it is one function of these schematas to ensure their gratification. Thus, these schematas are embedded in the motivational system. In realizing his/her personal interactional style, the individual experiences his/her identity and this emotional state in itself has a motivational quality. The individual feels driven to repeat this experience, he/she will search for appropriate situations or will make them suitble for having this experience. If necessary, he/she will unconsciously lead interaction partners to create the expected emotional atmosphere. This is what is called "re-enactment".

Normally, even in a child the ensemble of self-schematas is complex and manifold, comparable to the spectrum of sounds that can be produced on the keyboard of a piano. A mentally retarded child may use only a few keys. His/her identity is less differentiated and so are the emotional states he/she can experience. Specific self-schematas don't fit together well, causing disharmony in the interactions. In the case of psychically disturbed mentally retarded children, the self-schematas often have an additional shortcoming. They have archaic qualities often reflecting threatening experiences of early infancy. Consequently the "re-enactments" are simple, dramatic, and often violent. This I call a "pathological identity".

The theoretical construct of a pathological identity having a motivational quality appears necessary to explain certain, frequently observed psychopathologic interactions in families or groups with mentally retarded and psychically disturbed children. One often can observe stereotype sequences of pathological interactions which, again and again, lead to exactly that behavior which the parents or caregivers aim to prevent. Thereby, they may give up their principles and may become rigid, devaluating or even openly aggressive. Still, the child ignores all negative consequences. As if it were an addiction, the child strives for this particular emotional state which is part of its sense of identity. This could be, for example, the feeling of being grandiose and omnipotent, or a hated, rejected, and abused child. This phenomenon is similar to the so-called "repetition compulsion", which is usually explained by the hypothesis of an unresolved unconscious conflict. This may be true in many cases of neurotic disturbnces. However, in the psychoanalytic literature (Emde, 1988b; Hoffmann & Hochapfel, 1987; Sander 1985) the hypothesis that such repetitions can also be interpreted as an individual's problem-solving attempts, in other words, as an adaptive behavior, has received increasing support

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recently. Ihe reason why such behavior is constantly repeated in specific situations is because the individual does not have any other resources available. According to Sander, an individual re-creates situations where continuity and familiarity can be experienced so that the he/she has an opportunity to perceive himself or herself in a very specific relation to the other. Obviously, the objective is to ensure a continuity of self-awareness across all stages of development. This is very close to the notion of Sandler and Joffe (1969) who speak of a need to maintain a "feeling of safety".

The personal spectrum of experienced emotions can be seen as the basis of the indivdual's identity. Hence, one could say that the individual provides for himself oppurtunities to re-experience his identity including the accompanying characteristic emotions. From this point of view, such repetitions are of prime importance for the organization of normal and pathological social interaction.

Learned strategiesNaturally, learned behavior strategies also have an important influence on the child's interactions. Forced to exist under adverse living conditions, a child will learn to protect him/herself and to make his/her way in a manner shaped by these conditions. Later, this behavior often cannot be understood anymore and is described in psychopathologic terms. Furthermore, any symptom, whatever origin it may have, can be used as a protective mechanism or as a powerful instrument to succeed in the struggles of everyday life. In these cases daily life will become normal through behavior therapy.

Therefore, the problem is how to find out whether particular symptoms have been learned or not. In many cases this may be difficult or even impossible to decide. Theoretically, the differentiation is not difficult. Harold Lincke (1981) offers a convincing approach in accordance with psychoanalytic developmental psychology. He assumes two different processes of adaptation, one called "social adjustment (`Angleichung`)" and the other "adaptation by learning". Through "social adjustment" the infant assimilates his/her basic motivational system in accordance with the affective patterns experienced within his/her significant object relationships. Inanimate and animate objects receive a motivational quality which may not correspond to their objective properties. These experiences gathered in early interactions, along with th emotions which are bound to them, serve as the "axiomatic basis" (Lincke) for the assignment of affective meanings. According to Lincke, this process is not comparable to respondent or operantlearning. Learning processes work on the basis of objects already endowed with motivational values. On that basis they build up a second, complementary motivational system adapting the first to the demands of reality. This process is called "adaptation by learning" by Linke. In contrast to "social adjustment", learning processes obey the principles of objectivity and rationality.

Therapy has to pay attention to this distinction. A mentally disturbed child cannot be reached by contingencies and consequences if his/her symptoms have their origin in a distorted axiomatic basis for the assignement of affective meanings. These cases present the real therapeutic problems. Modifications are only possible if the child has the chance to build up a therapeutic relationship. Scientific research has not yet been able to pinpoint exactly which factors play a significant role in the therapeutic process. However, it seems reasonable to draw a comparison to the principles of early childhood

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development. A relationship which is supportive of development, similar in quality to a good parental relationship, is a prerequisite for any form of therapy. Emde (1988) speaks of "emotional availability" as the critical factor for normal development of an infant as well as for a positive outcome of therapy. Under the protection of such a relationship, an opportunity for development arises and the child is in aposition to change his/her value system. Lincke calls this "adaptation by social adjustment". Consequently, psychotherapeutic methods for the treatment of mentally retarded children focus on the significance of the therapeutic relationship (Dosen, 1984 and 1990).

Diagnostic issues and requirement for psychotherapeutictreatment

This paper focusses on the psychotherapeutic process. So I will restrict myself to only a few remarks concerning diagnostic issues. The range of psychopathology in Neuerkerode is the same as that usually found in similar institutions. In order to decide if psychotherapy is required, it would be inappropriate to categorize the observed psychopathology on the basis of one of the typical psychiatric classification systems. There is no such thing as psychic disturbances without a psychodynamic aspect. In fact, psychotherapeutic considerations should be part of any comprehensive treatment strategy. The risk of psychotherapy proliferating boundlessly is diminished by the limited capacity of the psychotherapeutic services available to both children and adults; there are long waiting lists. Under this condition, only those with the most severe disturbances will get a chance. Usually these children are violently aggressive and autoaggressive. In this pragmatic way the question of whether an individual requires psychoherapy is answered.

It is worth mentioning that it is a rare exception for children with an IQ lower than fifty to be treated psychotherapeutically. This is merely an indication of our inability to adapt the psychodynamic approach to the specific problems in connection with a low developmental level. We agree with Dosen (1990) that the IQ cannot be a criterion for the applicability of psychotherapy. No matter which level the child has reached, psychotherapy means nothing else than fulfilling the specific developmental needs.

Even though the psychiatric classification is rather irrelevant, the diagnostic process is of outstanding significance for therapy to be successful. It is important to let the caregivers participate as much as possible in the diagnostic process. Through these diagnostic conferences, the caregivers and the therapist will be able to piece together various aspects of the child's life story, enabling them to understand his/her suffering and to respect it.

The diagnostic process should bring about an understanding of how various pathogenic factors contribute to abnormal behavior, such as developmental deficits (ego weakness, immature object relations, etc.), neurotic conflicts, organic factors, and learned strategies. Of course, the developmental level and everyday demands have to be considered. In the end, the diagnostic process should result in a comprehension of the way the child is organizing his/her life using healthy as well as pathologic capacities. Then, based on this understanding of the child's identity, therapeutic goals can be determined.

Some aspects of the therapeutic process will be illustrated by a typical example:

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Brigitte was 9 years old when she was admitted to Neuerkerode. Until then she had been living with her foster-parents. Her real parents are unknown. She spent the first three years of her life in different hospitals. The reasons for admission to Neuerkerode were repeated, severely aggressive outbursts at home and at school. After weeks in a children's psychiatric clinic the diagnosis was still not clear and neuroleptics did not help much. Brigitte had a failure to thrive syndrome when she was an infant and a long history of behavior problems like crying spells, self-mutilating behavior, periods of overeating and disruptive behavior. The level of retardation was classified as moderate. Verbal communication was possible, but she was not able to learn reading or writing. In the first six months after admission, Brigitte showed depressive behavior such as clinging to the caregivers, problems with eating and sleeping, and rejecting contact to other children. In connection with repeated separations from caregiver a tendency toward increasing destructiveness was observed. After one year at Neuerkerode the caregivers looked upon Brigitte as "the little devil". At this point the psychiatric service was informed. The atmosphere of Brigitte's group was stamped by the fear of her outbursts. Sometimes there was a recognizable reason for her behavior; more often however, she tried to create a cause herself by provoking the caregivers or the other children. Being "the little devil" had become an important part of her identity.

The therapeutic process

The therapeutic procedure is oriented to the principles of therapy of patients with a preoedipal pathology as described by Heigl-Evers et al. (1983, 1985). So-called "psychoanalytic-interactional psychotherapy" allows the application of the psychoanalytic method to patients with severe ego deficits. It is based on the theoretical work of Kernberg (1981) on the psychoanalysis of patients with borderline personality organization. The differences between this approach and the therapy of neuroses can be illustrated on the basis of the following aspects: therapeutic goals, duration, therapeutic space, therapeutic media, therapeutic alliance, setting, transference relations, and interventions. These differences are accentuated in therapies of mentally retarded persons.

Goals and duration of therapySignificant and stable structural changes can be attained, but usually severely disturbed children don't become "normal". In any case, in the course of an individual therapy the therapist acquires knowledge concerning the specific vulnerabilities and capabilities of these children. Thus, he/she is enabled to advise the caregivers how to create suitable and pleasant surroundings for them. The children, then, can remain stable because their coping capacities are not overtaxed. On account of the ameliorated emotional climate they may re-enter their interrupted developmental process. To maintain this atmosphere, it generally becomes necessary to continue the therapy in a different way after having ended individual therapy. Gradually the therapeutic relationship will change its quality. The therapist is then no longer an auxiliary ego. Instead, his/her role will become more like an influential advisor, a function, which he/she can transfer to the caretakers at the end of the process. As we can see, it is difficlt to determine the duration of the therapy.

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Nevertheless, the individual phases should be clearly defined and the official end of therapy should be stated as early as possible. An adequate timing schedule will have a stimulating effect on the therapy. Usually psychotherapy on an individual basis takes about two to three years; supportive therapy may continue for several years beyond that.

Long after the individual therapy was finished, Brigitte was still struggling with her destructiveness and sometimes she was not able to control it. But the caregivers could handle it much better now and reinforced Brigitte's own control ability. A learning and adaptational process took place on both sides. Both the caregivers and Brigitte herself requested therapeutic advice when they had need of it. Six years after beginning, the therapy was officially declared over. Today, she is still seen as a difficult young woman and is treated by the caregivers with consideration, but she has organized her private life in a quite satisfactory way. In the case of an emergency Brigitte knows where she can find her former therapist.

"Therapeutic space" and "real space"Usually, mentally retarded children are not able to demarcate themselves well adequately from their social environment. They live more in their social relationships than within their inner structures. Their moods, responsible for their problems of adaptation, fade out very slowly and outlast the triggering situations for a long time. These children are not able to associate correctly these moods with internal or external causes. Thus, affects aroused during the therapeutic session will provoke conflicts at home and vice versa. In addition, these children have immature defense mechanisms, leading to an inevitable involvement of the caregivers. The most frequent example is "splitting" the objects in "all bad" or "all good" ones. The therapist then will often be suspected of stirring up the patient against the staff. Finally, the therapist has to prevent an increase in negative counter-transference affects on the part of the caregivers; otherwise his/her therapy will be ineffective.

So there are many good reasons for doing without the strict separation of "real" and "therapeutic space" usually demanded by psychoanalytic therapists. The therapist has to work on both sites. He/she should also have an influence on everyday life in order to prevent unnecessary frustrations and stress. Thus, individual therapy is only one part of a comprehensive therapeutic strategy. The therapist has to organize and coordinate this complex process. Of course, the prescription of psychiatric drugs must also be discussed with the therapist.

Soon after therapy had started, it became even more difficult for the caregivers to get along with Brigitte. In arguments between the caregivers and Brigitte, she always used the pretext that her therapist had given her permission. One could not always depend on Brigitte to reliably separate her wishful thinking from reality, and so conflicts flared up time and again between the staff and the therapist. Brigitte registered the contacts between the therapist and the staff with deep mistrust. She often reacted by withdrawing her trust completely. Therefore, it became necessary to appoint a different therapist to counsel the staff. In this way, the splitting that Brigitte had started was taken over and even heightened for the time being. Brigitte reacted towards the loving care of the caregivers

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with contempt and hate making them feel helpless, but also angry. This threatened to develop into permanent rejection of Brigitte. Particular indications of this happening were exaggerated disciplinary measures and a nelecting, indifferent attitude. The situation also became more difficult because Brigitte had learned to use temper tantrums as well as self-mutilation in order to get what she wanted. The caregivers were expected to keep up an empathetic, emotionally open attitude and still be as consistent and firm as was necessary. The task of the other therapist was to support this affective attitude.

Therapeutic allianceAs a rule, children starting therapy do not have any insight in their illness and usually do not suffer from their disorders. For this reason they have no desire for therapeutic treatment. The other children who have to live together with them and the caregivers are the persons affected by the symptoms. Still, in many cases it is incorrect to automatically assume that the caregivers see the necessity for therapy. They are often wary of the therapeutic procedure and try instead to influence the disorders with disciplinary measures. In such cases it is pointless to start therapy. Here, the initial task of the therapist is to first establish the prerequisites so that therapy can take place. Only after the caregivers have been convinced by the therapist a contract, laying down the conditions for cooperation and defining the individual areas of responsibility, can be set up. This is the first step. This does not mean that the contract with the child is any less important; it is just not regarded as a preconditin for initiating therapy. Instead, it is the first goal. Often it is necessary for the child to first learn the problematic and disadvantageous nature of his/her interactions or to associate distressful feelings of unpleasure with his/her own behavior.

So, the therapist can't always count on voluntariness on the part of the persons he/she has to deal with. Even a mentally retarded child may quickly register the therapist's intentions and oppose the planned change of his/her personality. The child reacts with resistance. Therefore, the therapist must first build up the necessary motivation by making therapy as attractive as possible. But then, step by step, the therapist will make increasing demands on the child by setting up agreements, thereby aiming at having the child participate in the therapeutic process in a responsible manner. So, drawing up such a contract is not a one-shot deal; instead, it is a process in itself in the initial phase of therapy.

At first, Brigitte would only meet the therapist in her own room in the group residency. The caregivers had attempted to explain the importance of the therapy which was about to begin to Brigitte - she interpreted what they told her in her idiosyncratic way. She saw it as a form of punishment. Brigitte began the first session with protestations such as "I didn't break the window pane" or "But I made up for it". The therapist ignored these comments; instead, in a very general way he expressed that he was concerned about her and offered his support. This offer and his concern made Brigitte curious. At the same time though, she became suspicious- the therapist interpreted this as a sign that she perceived a deeper meaning of the therapy offer and as a first indication of resistance. In the following therapy sessions the therapist had to meet Brigitte in

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her room. He restricted himself to inquiring how she was feeling. Only in the fourth session she was willing to leave the group residency with the therapist ad in the next session it was possible to arrange for her coming to the therapy room for her next appointment; the caregivers would tell her when to go. In connection with this arrangement, the goal of therapy was formulated with the words "I want to help you".

In the following sessions the therapist tried to build up a pleasant atmosphere. Various offers were made to Brigitte (drinking hot chocolate, eating cake, sitting idle). She was allowed to decide at what time she would like to go. After ten sessions it was possible to come to an agreement regarding the length of the sessions ("until the alarm clock rings", which corresponded to thirty minutes). At first, her attachment to the therapist was perhaps based on the vague expectation that something in her life could turn for the better; surely, though, her hopes for an increase in prestige played a small role too. Brigitte had noticed that others envied her. In the course of time, her interest in the therapist as well as in the emotional atmosphere of the therapy session increased. At the same time, aggressive clashes with the caregivers of the group residency became more intensive. This was unintentional, but could not be hindered by the therapist. An alternative experiential world, which the therapist deemed neessary, had been established for Brigitte and so the therapy was able to enter a new phase.

Setting, therapeutic mediaWhat was said above concerning the length of the individual therapy and the consideration of the social environment already illustrated some important aspects regarding the setting. The setting must be variable because of the diversity of disorders and differing developmental levels. Still, the principle of regularity and reliability must not be violated. This is one of the most important prerequisites for developing and keeping up a viable therapeutic relationship.

The frequency and duration of the individual sessions will vary depending on the type of disorder. It may be impossible to stay alone with the child in a room, for instance, because he/she may be too frightened. In this case it is necessary to find other alternatives (for example, going shopping together, pursuing leisure activities, etc.). It is possible and appropriate to implement a non-directive approach with some children. In most cases however, it is necessary to structure the therapy session while refraining from supressing the child's own initiative. It is indispensible to show the child his/her limits. Assaults on the therapist as well as destructive behavior must be prevented. It may become necessary to lock the room because otherwise the child would be constantly running out. Such restrictions do not disrupt the therapeutic relationship if the therapist does not relinquish his/her unlimited good-will. On the contrary, one may presume that the strong, but benevolent character of the therapist is imortant for the identification processes which ultimately lead to change. An unclear setting and a "soft" therapist can contribute to making the child chaotic and so inhibit his/her development.

The therapist must be able to offer a broad spectrum of therapeutic media in accordance

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with the respective developmental level, which varies from individual to individual. Verbal techniques are effective, but they must be even more capable of overcoming the individual language barriers of the mentally handicapped child as in "regular" child psychotherapy. Frequently, verbal interaction may drop completely into the background. The therapist must learn to decode the symbolic content of nonverbal interaction and to respond accordingly.

The main objective of all media, including dialogues, is the manifestation of the specific individual interactional style. From this interactional style the therapist is able to identify the dominant transference tendencies, phase-specific needs, and deficits of ego-functions. In this respect, an alternative experiential world is opened up for the disturbed child, offering possibilities for novel emotional experiences through the interaction with the professional therapist. Therapeutic media which are implemented in this context include playing, puppet-play, painting, clay modeling, cooking, body-oriented interactions, shopping, sports activities, etc..

It was difficult to carry on a dialogue with Brigitte. She often expressed something in everyday language which had a special meaning for her. This regularly led to misunderstandings. The fact that she was not able to separate fantasy from reality heightened the confusion. So for quite a while, the mediation of emotional experiences was more important than verbal communication. If Brigitte was upset, she sought physical closeness to the therapist. She would sit in his lap and let herself be rocked while he spoke to her soothingly, like a gentle mother would. A fixed ritual was that the therapist regularly put salve on her scratched and scarred arms. With these two measures the therapist responded to Brigitte's obvious needs for being cared for and for security. These were the dominant needs in this phase. Because Brigitte refused to play anything at all, the sessions were structured by mutually cooking and drinking hot chocolate. In the initial phase of therapy which stretched over six months, Brigitte verbaized the (imagined) torments, humiliations and injustices her caregivers were inflicting upon her while pursuing this activity. At a later stage the verbal contents became more realistic and were more related to her own achievements (these were also imagined to a great extent), which she wanted to be appreciated. For about two years this structure remained stable, while the interactional style and the verbal contents gradually changed. The individual sessions lasted 45 minutes and took place two times a week. After two years had passed, there was hardly body contact any longer; neither were they drinking hot chocolate together anymore. The sessions were held only once per week and were characterized by Brigitte reporting what had happened that week. This type of therapeutic contact had to be kept up for another three years (this was evident, among other things, from the fact that Brigitte regularly fell into an unstable mental state if the therapist was absent for a longer period of time). Thereafter, regula sessions were no longer necessary, but the therapist was available for Brigitte if she needed him.

Object relations, therapist as a "real object", interventionsThe therapist's goal is to build up a relationship resembling the one an infant has with

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his/her parents in many aspects as early in the therapy as possible. It is a dependent relationship which facilitates further development. Due to the exclusive character of the relationship, the therapist carries a great deal of responsibility; from the start he/she must strive for the termination or transformation of this relationship through therapy. Often, unavoidable conflicts with the staff are another result of this exclusive relationship. These must also be resolved so that therapy can be successful.

Often it is quite difficult for the therapist to achieve such a therapeutic relationship. The children, usually extremely disturbed, act out the terrible experiences of their infancy once more in therapy. They fight to keep up their pathological identity and tend to choke every endeavor to help. In this phase, the stability of therapy rests solely upon the attitude of the therapist who, by means of his/her intense interest in and unwavering concern for the child, eventually makes him/her receptive for a therapeutic relationship.

It is difficult to deal with these repetitions of dominant object relations of early childhood in therapy. Quite often one is confronted by archaic, unrestrained affects of hate and envy or by panic-like fear. These object replication are more difficult to release than transference relations in neurotic children. These children are not able to dissociate themselves from this experience. At first, they see the therapist as really having those characteristics they endow him with by means of their projections. The therapist cannot maintain a neutral position. Due to his/her therapeutic training, the therapist is capable of reflecting upon the real reasons behind the types of interaction he is confronted with, and searches for an "answer" by analysing the counter-transference feelings aroused in him/her. This answer should be "authentic" and "selective" (Heigl-Evers & Henneberg-M"nch, 1985). Authenticity is necessary so that the therapist's emotional understanding and respect for him/her can be portrayed to the hild. The answer must be selective because the therapist must take the cognitive and emotional limitations of the child into consideration. The "answer" must be of use to the child; it should stimulate an interest in a continuation of the interaction, make the child curious and courageous. In the course of this, though, the therapist will not be able to avoid frustrations. Still, he/she will choose the "right" type and the "right" moment so that the development of the child will not be inhibited, but supported. If therapy is successful, this type of interaction will eventually lead the child to modify his/her object relation patterns and their affective qualities, and adjust them better to reality.

The therapist's "answers" are simultaneously his/her interventions. They may be expressed verbally, but they can also have an effect in the form of facial expressions and gestures or through actions. The "answers" should express agreement and congruence as well as difference and dissent. Their purpose is to confront the child with experiences of emotional reactions and to facilitate their clarification and differentiation. At the same time, the "answers" mediate emotional experiences such as protection, security, respect and love. In this emotional atmosphere the child will be able to develop his/her ego functions under the guidance of the therapist. The emphasis here is not so much on the training of such functions. Instead, in the role of the auxiliary ego, the therapist takes partial control of these functions during the interaction. This facilitates the adoption of more suitable adaptation functions through partial identification. As a substitute for the objects of the real world, the therapist enters th developmental process of the child as a significant object and serves as a catalyst.

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It is not possible to give a detailed account of the development of object relations and the therapeutic procedure during the long duration of Brigitte's therapy. As an example, an aspect from an early phase of therapy will be presented in the following. Brigitte did accept the offer to enter a relationship with the therapist quite quickly. The price for this, however, was an increase in aggressive behavior towards the inhabitants of the group residency. This was interpreted as splitting and was accepted for the time being. Besides, Brigitte's attachment to the therapist was still fragile. Deviations from her rigid rules and expectations provoked temper tantrums or retreat. Brigitte attempted to exercise total control over her therapist. In particular, she attached great importance to having the therapist share her ideas regarding her caregivers. The therapist interpreted these observations with the assumption that Brigitte was still not capable of reliably separating self and non-self. The therapist had becme a part of Brigitte's self in the manner of a self-object relation. Brigitte projected all her ideas of a "good, omnipotent mother" upon him, and was not capable of acknowledging his true characteristics. Each and every unpleasant expectation was projected into the external world, in particular upon the caregivers. In this phase the therapist attached importance to first fulfilling Brigitte's need for safety and security. He did not attempt to correct her misconceptions concerning her caregivers. He tried to soothe her and make her relax by means of body contact (for example, holding her in his lap) . Moreover, he tried to live up to her expectations as far as possible. The next developmental task for Brigitte to fulfill was to aim for an increased differentiation between her self and the significant object, in this case, the therapist. Such a change of object relations would make progress in the development of various psychic functions possible and necessary (for example, reality testing and the beginnins of empathy, etc.). The therapist was forced to wait until he was convinced that Brigitte would be able to tolerate a deviation from her usual expectations which he would provoke. The risk for the therapist was that Brigitte could suddenly equate him with the "bad" caregivers and repudiate him. However, if the therapist would be successful in this endeavor, the staff would have the chance of forming a more realistic relationship with Brigitte. So, the therapist started introducing changes in the course of the session. Each individual change appeared rather unimportant and trite; yet, the sum of all these modifications enabled the patient to experience a significant change. In this case the therapist chose their mutual drinking of hot chocolate as a starting point. Knowing that it was very important to Brigitte that he would prepare the hot chocolate and then drink it together with her, he told her that he did not want to drink any hot chocolate in one of the sessions. After Brigitte had accepted his decisio, he made the suggestion in one of the following sessions that Brigitte could prepare the hot chocolate herself and he would brew himself some tea. After a while it was possible for him to make a verbal evaluation, such as "I prefer tea and you like hot chocolate". The emotional atmosphere of the sessions could now be changed; what Brigitte needed now instead of security, protection and warmth was pride in her own achievements (for instance, cooking the hot chocolate herself, having her own taste) and acknowledgment by the significant object. Under the therapist's guidance, many little steps became possible which imparted novel emotional experiences regarding herself and her significant

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object, namely the therapist. These experiences eventually led to a step-wise modification of her self-concept by means of identification processes. Today, Brigitte is no longer "the little devil", who wants to turn the group residency into a state of chaos. Instead, she is a young woman with personal everyday habits and relaively stable relationships with the persons she lives with. Under emotional stress, though, her object relations disintegrate easily and she regresses into her split world in which she feels pursued by the hate of her objects.

Evaluation of treatment - an unsolved problem

One factor which makes an evaluation of the outcome of such a therapeutic concept so difficult is the fact that the treatment plan evolves within the course of therapy. Another problem is the selection of patients for therapy; the basis for selection was a pragmatic one: those that were chosen were the most difficult cases. The long duration of therapy as well as inter-individual differences in the number of necessary sessions make it clearly impossible to control for the effects for other variables, in particular the influence of medication and changes in the everyday living situation. Another problem is that the psychoanalytic-oriented approach, as described in this article, necessitates a very individual type of assessment, and consequently a highly individualized therapeutic procedure. This concerns the description of the presenting symptoms as well as the comparability of criteria for assessing therapy outcome. One therefore is confronted with the fundamental problem of how to apply a evaluation stratey in order to examine the effectiveness of therapy without seriously influencing the therapeutic procedure.

Because of the well known methodological difficulties associated with a psychoanalytic approach as a treatment method, it has traditionally relied on case studies in the evaluation of its effectivness. In this connection, the importance of this psychodynamic approach and its theoretical basis has been illustrated by means of extracts from a case study. As such the classical case approach in both evaluation of the individual treatment programme as well as the theoretical foundations has been utilized.

On a broader, much less specific spectrum, another form of data is available. The essential datas are case notes of fifty-five children. The basic appraisal of client progress is based on the staff's evaluation of the extend to which the disturbing symptoms have receded and of the degree to which day-to-day life with the client has become less difficult. The overall results are encouraging. Only in two cases out of fifty-five it was necessary to break off therapy because of serious conflicts between therapists and caregivers. Symtomatology did not become worse in any case. There is consensus among staff treating and caring for these clients, that symptoms improved to a satisfying degree in thirty-one cases; day-to-day life with the clients judged as significantly less problematic was found in forty-five cases.

While plans for the collection of broader and more varied data to evaluate and develop this therapeutic approach are being considered, the evidence from these cases is regarded at least sufficient to support the use of psychodynamic treatment with clients who are

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mentally ill as well as mentally handicapped.

Conclusions

In spite of numerous shortcomings (Robinson & Robinson, 1976; Ollendick & Ollendick, 1982; Konarski & Cavalier, 1982) the psychodynamic approach can be of importance for the therapy of emotionally disturbed mentally retarded children and adults. Every diagnostic and therapeutic concept will shape the attitudes of those who care for them. A basic assumption of the psychodynamic approach is that vulnerability to psychic disturbances is - besides other factors - a result of emotional experiences with significant objects of early developmental phases. Consequently, psychodynamic therapy focusses on the client's relationship not only to his/her therapist but especially to other staff. To a greater degree than other therapeutic approaches, psychodynamic therapy stresses the importance of the emotional atmosphere for stabilization and further development. Through the professional support by the therapist, the caregivers may learn to see deviant behavior as a result of developmental deficits and to have respect forthe handicapped person and his/her effort to organize him/herself and the social environment. They may acquire the empathy necessary to perceive developmental needs and conflicts, which may give them the flexibility necessary for an appropriate emotional response to the client's behavior. Finally, they may experience how they are involved in the psychodynamics of the clients, and be able to interrupt the vicious cycle of transference and counter- transference by stabilizing their relationship just by "good parenting". This influence on the caregiver's attitude may be the most important contribution of the psychodynamic approach.

In many cases this effect can be attained by counselling the staff without having to perform an individual psychotherapy. However, an individual psychotherapy is often necessary to gain knowledge of the specific psychodynamic background of the child's behavior and to have the opportunity for phase-specific interventions.

The experiences we have had with this concept at Neuerkerode are encouraging. The fact that transfers of children and adults to psychiatric hospitals have become rare exceptions (this happened only twice in the last ten years); as well as the low rate of administering psychiatric drugs (about 20 percent of all residents receive medication) may lend support to our assumption. While there is no unequivocal evidence for the efficacy of this approach and while the psychodynamic interpretation may be looked upon as speculative it has enriched psychiatry and psychology more than other theories, and it may be assumed that this will also happen in the field of mental retardation.

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