The role of the psychoanalytically oriented psychotherapist within a therapeutic community

This paper presents a theoretical model for the psychoanalytically oriented psychotherapist working in a therapeutic milieu in which the standard psychoanalytic situation is altered in three respects: (1) the patient is borderline or psychotic and has difficulty participating in a verbal, insight-oriented approach, (2) the therapist is part of a treatment team, and (3) the patient is treated while in a community setting. These three factors can create difficulties in treatment, which will be reviewed with the goal of delineating a model to guide the therapist as he or she responds to the multiple stimuli of a therapeutic community. The role of the therapist will be examined from two broad points of view: the nature of psychotherapy with borderline and psychotic patients within the milieu, and the interaction between therapist, treatment team, and therapeutic community and its effect on the patient. Certain aspects of transference and countertransference in milieu treatment will also be discussed.