Staff counter-transference in the therapeutic milieu: creating an average expectable environment

Counter-transference, investigated and described as a powerful technique in individual psychoanalytic psychotherapy, has been less extensively studied in the psychodynamically oriented milieu therapy of more regressed patients. Features of the setting of the psychodynamic milieu are suggested which foster the use of the staff's counter-transference (evoked feelings) as a therapeutic tool. Several clinical examples are given which highlight the features necessary (1) to create a moment of illusion for the patient; (2) to create an observational frame of reference for the staff; (3) to clarify when certain intra-staff differences about the patient's therapy reflect the patient's re-creation of intrapsychic lacunae or conflicts among the staff. The importance of action is discussed as a means of communication for regressed patients. This concept is reconciled with Loewald's stance that feelings and actions should be represented in words. A developmental hierarchy of interpretation is suggested which involves several levels of action, through levels of symbol. A review of the literature supports this hierarchy. Both in the consulting room and in the psychodynamic milieu, the phenomenon of evoked feelings (counter-transference) offers an interface between two sets of internal laws: the therapist's and the patient's. The therapist's task is to treat these two sets of laws with mutual respect, offering the patient an opportunity to experience a successful autonomous act, that is, affecting his or her therapist. This concept, when extended to the psychodynamic milieu, treats the milieu as a social organism that requires ongoing observation and revision by all its participants.