Keywords

1 Introduction

The cultural values of the post-war generation in Austria are often rooted in the many deprivations they experienced during the War and the scarcity of resources in the subsequent post-war years of reconstruction. The values that were formed during these years continue to have a powerful effect and influence how values are experienced, and how interactional situations are evaluated and interpreted down to the present day.

At the same time, for Austrians in general and for those who live in eastern Austria in particular, a rich and rewarding life has always been a central life goal and this is defined not just as a good and successful life, but above all as a life rich in pleasure [1].

The following study (which is presented in four parts) describes the shift in the values of a woman to whom, in her own words, fate had always been cruel, who had always had a harder time than others and whose efforts had always been directed to being able to keep up with others and not towards self-fulfilment. At the same time, there is an interaction between the patient’s initial adverse and existentially threatening circumstances and cultural and pathological determinants. The ‘healing process’ is to a large extent also influenced by the shift in values prompted by the therapy.

2 Case History (Part I): The Loss of Beauty

Frau S. is a 73-year-old woman who for 15 years has been undergoing regular treatment for her addiction at the Anton Proksch Institute. The Anton Proksch Institute is Europe’s largest addiction clinic and treats approximately 2000 inpatients and 8000 outpatients per year. In addition to treating addictions to substances such as alcohol, medicines, illegal drugs and tobacco, the Institute has for approximately 10 years treated non-substance addiction disorders , i.e. addictive behaviours such as pathological gambling, and addictions to computer games, shopping and work.

The patient suffers from an alcohol dependency against the background of a multiple post-traumatic stress disorder and a depressive disorder. The patient comes from a very modest family background, grew up in Meidling, a part of Vienna with a high proportion of working-class residents, and she herself worked as a building caretaker, sales assistant and in the hospitality industry. Despite a very intensive and regular employment history, the patient was often at risk of poverty. Her childhood was dominated by the existential anxieties of her mother who, because of her own occupation, was only able to provide limited resources for raising her daughter. Until the age of 12, the patient lived alone with her mother whom she cared for until the latter’s death despite a very ambivalent relationship. The identity of her father is still unknown. Her mother’s second husband, and here financial considerations probably played a role in the decision to get married again, abused the patient physically and sexually over a period of several years. At the age of 16, the patient moved in with an acquaintance of her mother to escape the violence. Although the patient confided to her mother that she had been sexually abused by her stepfather, her mother either did not believe her or did not want to believe her due to fear of the drastic existential consequences this would have. ‘Nothing can happen that isn’t supposed to happen’ the patient remarked many years later during her therapy. The mother’s lack of understanding exacerbated the patient’s feelings of guilt and shame. As only money and financial security were considered to bestow a certain degree of social prestige and status, the matter was not discussed further within the family. As a result, it became a family secret that only came to light decades later during therapy. From a psychological-therapeutic perspective , the fact that the daughter cared for her mother until the latter’s death, despite the lack of support she received to end the sexual assaults and the mistrust and contempt the mother showed for her daughter, are of central importance. The ambivalence this produced in the patient of approach-and-avoidance feelings —this is my biological mother accompanied by simultaneous feelings of hatred and death wishes directed against her mother and herself—persisted for many years even after the mother had died. For example, it is only in the last few years that the patient has been able to visit her mother’s grave. Due to a lack of alternative possibilities caused by the fact that at the same time she was solicitously caring for her mother on a daily basis , the patient redirected the negative destructive feelings she had towards her mother towards herself. In addition to self-harming and massive episodes of intoxication as well as periods of gambling in an effort to improve her financial situation, her attitude to religion and to humanity as such also underwent a massive change.

One aspect of the patient’s biography that has not been mentioned so far is her homosexuality. In Roman Catholic post-war Vienna and among her working-class friends, homosexual people often faced hostility, mockery and discrimination. Moreover, her love for another woman developed at a time when her future partner was still in a relationship with a man. He stalked her in later years calling her out as an adulteress.

In 2002, the patient first sought professional help to tackle her addiction. Her decision was triggered by an acute coronary syndrome combined with major physical impairments caused by chronic alcohol abuse. When her doctors told her she would not have much longer to live if she did not change her ways it prompted her to begin treatment for her addiction. The patient was admitted to the Anton Proksch Institute for the first time for an 8-week course of treatment as an inpatient. As she repeatedly said of herself afterwards, she had not really been able to engage with the therapy at the time; nevertheless, following treatment she was abstinent for approximately 1 year. After suffering a relapse during a moderately severe depressive episode, she was readmitted for further in-patient treatment. Unlike her previous stay, the patient this time came into contact with the newly introduced Orpheus programme of treatment.

3 Digression: The Concept Behind the Orpheus Treatment Programme

In Greek mythology, Orpheus was an inspired singer. When Orpheus and the Argonauts were sailing in search of the Golden Fleece, they came across the sirens, the notorious bird-women of antiquity whose sweet and seductive song promised passing sailors beauty and pleasure, but instead brought death and destruction. Anyone who hears the sirens is lost. It was said that those who heard them were burned up with passion and indeed it was the case that everything around them turned to dust and ashes.

However, there were at least two famous ancient heroes who succeeded in passing the sirens unscathed. Odysseus and our Orpheus. Odysseus had his men tie him to his ship’s mast and ordered the crew to seal their ears with wax in order to resist the temptation. Orpheus chose a different method that would enable him to pass the sirens with lust and pleasure and that would allow him to live a full and rewarding life. When he and the Argonauts sailed past the sirens, he took his lyre and sang so beautifully that he drowned out the sound of their singing—he played the better music.

This ancient myth forms of the basis of the Orpheus programme of treatment at the Anton Proksch Institute. The therapeutic goal of abstinence is often associated with such negative attributes as self-denial, sacrifice and compulsory life-time abstinence, and is, therefore, often seen by those concerned as unattractive and not worthwhile. In the Orpheus programme, abstinence is only presented to individuals suffering from an addiction disorder as an opportunity for a transformation process within the scope of the therapy; the actual goal is autonomy and a full and rewarding life. This therapeutic goal has enormous motivational and volitional power , however, for many patients, including Frau S., it means totally reorienting their lives and ultimately also learning to manage their own lives. In addition to the mindfulness and cosmopoesis (or new design for life) modules in the Orpheus Programme , it is above all the elements focusing on experiencing pleasure and exploring what is beautiful that induces a change in values and attitudes that is effected by the patient himself (e.g.: learning to enjoy social interactions again).

4 Case History (Part II): Recovering the Beautiful

In this way, Frau S. was gently led back to the beautiful . During her after-treatment and continuing treatment as an outpatient following her second course of residential treatment, the patient was gradually able to perceive beauty more frequently and more intensively again. This is certainly not something that can be taken for granted, given that addiction in itself, but also the comorbidities such as post-traumatic disorder and depression also often lead to a loss of beauty. Subsequently in the face of beauty the patient was once more able to perceive first emotional stirrings , a feeling of being infused and a longing for the beauty in herself. With increasing frequency she reported having had stirring experiences of nature, such as extraordinarily beautiful plants and encounters with animals (e.g. birds) that moved her and inspired her to reflection; later on, she described beautiful encounters with other people. Someone to whom ‘fate has been so cruel’ is extremely negative, contemptuous and hostile towards themselves . Typical cognitions in this context are ‘I don’t deserve this’, ‘I’m not entitled to it’, and many individuals prefer to remain trapped in the suffering that is familiar to them than to embark on new, perhaps much more beautiful, but uncertain paths.

The patient’s recovery process and the shift in values associated with it was not one of steady progress; on the contrary, she suffered repeated relapses. Her core assumption that ‘fate was cruel to her’ was experientially confirmed many times in a dysfunctional form and led the patient to even greater passivity and into a victim role. Thus for example, on the day she was released from her second period of residential treatment, the patient, who had been diagnosed with claustrophobia, got stuck in the lift when she came home and a short time later was robbed in an underpass during which she received a minor injury to her arm. This list could be continued almost ad infinitum and the reader would indeed begin to develop a similar view of the patient (that fate was cruel to her), but this case study is instead concerned with describing work with aesthetic values. To this end, the therapeutic process began with a reflection on the experience of pleasure in an inpatient setting , but above all during the after-care Frau S. received as an outpatient.

5 The Values Arising in This Story

Spiritual values , which had formerly been a resource, were largely lost as a result of the way those around her dealt with the traumatisation. ‘A God who lets that go unpunished, is not a God I can believe in’. Subsequently, as is typical for traumatised patients and especially for victims who have experienced sexual violence, the patient turned her back on and distanced herself from other people. Cultural and aesthetic values , as these are almost always created or updated in social interaction with others, became increasingly less important. In contrast, through her own illness, her feelings of being under existential threat were again intensified.

Addictive substances in general, and in the case of Frau S. alcohol in particular, are usually used as problem solvers. Similar to medication, for example, against headaches, the consumption of psychoactive substances alleviates symptoms in the short term, but in the long term leads to a deterioration in the patient’s condition which becomes chronic. Coping strategies that perhaps existed to a certain degree in the past are pushed increasingly further into the background in favour of the addictive substance. The loss of control—the cardinal symptom of dependency disorders —exacerbates this effect and leads to learned helplessness and feelings of guilt and shame in the face of the negative consequences arising from intoxication. During the period when she worked as a building caretaker, the progress of her addiction meant there were phases during which Frau S. was unable to carry out her duties properly, although this was tremendously important to her as she had a very highly developed sense of responsibility. Those around her, the tenants in the council block in which she worked, increasingly began to make complaints about her and as her excessive alcohol consumption became evident, the patient increasingly found herself on the receiving end of pejorative and addiction-specific stigmatising comments. Due to the depressant effect of alcohol, her sustained consumption led to her developing a manifest depressive disorder.

6 The Influences of Culture on This Story

For centuries, Austria has had a strong beer, wine and schnapps culture. It is impossible to imagine social and cultural life without alcohol. Austria regularly ranks among the top three nations worldwide for per capita consumption of alcohol. In a country in which alcohol is an innocuous and firm part of many rituals on almost all occasions, the line between what is considered to be socially ‘normal’ levels of drinking and a pattern of consumption that is considered to be ‘abnormal’ or ‘pathological’ is a very fine one. A man who can take his drink is still considered to be a ‘real man’, the threshold for women is significantly lower and society is still quick to ascribe negative attributes, although no longer to the same extent as in the past, to women who consume large quantities of alcohol. This is of particular relevance for the progression of an addiction, as this negative attribution and ultimately the stigmatisation, often results in an addiction continuing to grow in secrecy. Thus, in Austria, approximately 10 years pass from between the time when a patient first manifests alcohol associated problems and when he or she seeks specialist assistance; during this period, the illness progresses and the prognosis for recovery worsens significantly with the continuance of the disease.

7 The Influences of Aesthetic Values and the Will to Beauty on This Story

In the case of addictions, and depressive disorders in particular, one of the first steps in treatment involves reactivating experiential capability , i.e. the ability to absorb impressions and to process them emotionally. It is one of the mental characteristics that develops on the basis of a person’s individual disposition over the course of their lifetime as a result of their experiences, acquisition of abilities, skills and knowledge. The diverse suggestions and reflections in individual counseling sessions and in the group session aim to strengthen this experiential capability and to bring it into the centre of the patient’s consciousness in order to increase their ability to experience pleasure. Pleasure promotes joy, reward, increased well-being and a lust for life. It has nothing to do with severe intoxication and massive alterations of mind. ‘Pleasure as the highest form of experiencing beauty should not be confused with fun or quick gratification and absolutely not—as is so often the case today—with consumption at high prices or in large quantities—on the contrary, pleasure stands for the ability to enjoy leisure and relaxation’ [2].

The repeated experience of pleasure subsequently raises the level of perceived self-efficacy [3]. Individuals who frequently experience themselves enjoying pleasure, i.e. who are able to put themselves into a sustainable positive mood, possess a more intense conviction that they will be able to successfully overcome difficult situations and challenges with their own resources. In the case of Frau S. this marked the first step in her coming out of her role as a victim and developing an eye for beauty. One of her first accounts of perceiving beauty concerned an experience of nature. She reported something she had experienced that we would like to briefly share:

8 Case History (Part III): A Key Experience of Beauty

Her partner died 12 years ago and until then she had only been able to live this relationship furtively and in secret. She began paying regular weekly visits to her partner’s grave. These visits were characterised by melancholy, grief and a desire to follow her shortly. Despite the immense suffering these visits triggered on each occasion, she persisted with them, driven on the one hand by a sense of supposed duty, and on the other, by a desire to be near her partner and ‘the woman of her life’. One day, the following occurred: as she was standing at the graveside weeping bitterly, a squirrel came and sat on her partner’s gravestone where it remained for what subjectively seemed like an eternity and studied her carefully. In the eyes of the beautiful and noble creature she was able to recognise an act of affection for her person—love and respect. She was so deeply touched by what was such a significant experience for her that in contrast to previous visits, where she had only been able to bear staying at the grave for a short time, she remained for a long time. This incident was picked up and reflected upon during therapy. She herself interpreted this encounter as a message and as permission from her deceased partner to live a full and rewarding life. This aesthetic experience characterised by the beauty of the encounter between an animal and a human being marked a milestone in the therapeutic work. For the first time in decades, Frau S. was able to grasp and to experience the beauty of the world in a brief fragment. To not just perceive the power of beauty but to feel it with body and soul and ultimately to utilise the power and energy that reside in beauty.

There is one key requisite for being able to grasp beauty that those who are traumatised and those who are suffering from other forms of mental illness do not possess in adequate measure, the will to beauty [2, 4]. Intrapsychically, this means caring for oneself, wanting something ‘constructive’ for oneself and to a large extent driving back destructive impulses, having a fundamentally positive attitude towards oneself and others, and ultimately towards the whole world.

Finally, we would like to consider the patient-therapist dyad in the context of Frau S.’ treatment and the extension and stabilisation of the process of turning to beauty that was triggered by the initial experience.

9 Case History (Part IV): Working Together Towards Beauty

In the ‘ homeland’ of psychoanalysis , the nature of the relationship between patient and therapist is traditionally characterised by distance, in the medical context frequently by a paternalistic attitude in which the therapist knows how it is done and the other person is told how he has to do it. However, to utilise the power of beauty for therapeutic purposes , the therapist is required to adopt a deliberate attitude as a ‘friend’. The task is to explore what has been experienced on equal terms—in the case of Frau S. to listen and nudge sensitively when she began to describe similar situations to the encounter with the squirrel. The patient was often overcome with doubt as to whether her view of things was the right one, whether people would consider her to be mad due to her intensive feelings of experiencing beauty in her everyday life. In this situation, the therapist’s task is not to confirm the correctness of these views as such, but to work to arrive at a place where what is subjectively felt and experienced is seen as being just as true and valid as if the entire world had unquestionably experienced it in the same way. Self-doubt and the orientation to the norms of others in combination with the taking on board of the values of the collective prevent a patient from opening up and engaging with beauty and rob these experiences of sustainable efficacy.

In addition, the therapist can serve as a model in sensing and experiencing beauty . The patient has the possibility through vicarious observation—even more through vicarious sensing—to experience exposure to beauty without fear and at first at a safe distance. Of course, these experiences are not as intensive and as strong as if the patient were experiencing them directly, but in many cases, they offer the necessary guidance and support.

The final aspect in the patient-therapist dyad in connection with the experience of beauty is the reaction of the therapist to the discovery of beauty in the patient themselves. The patient’s intrinsic beauty first has to be discovered and brought out in the therapeutic process. Praise, recognition and conscious appreciation in the countertransference process are suitable instruments to help the patient begin to identify his own beauty. On several occasions during Frau S.’ accounts of beauty, the therapist showed how moved he was by the patient’s experiences and provided feedback about his enthusiasm for the way she dealt with the situations and their observations. This increasingly reinforced Frau S’s affinity to beauty, it became an integral part of her personality and is still a helper in difficult times.

Six months ago, the patient was diagnosed with macular degeneration. The ophthalmologists who are treating Frau S.—a woman with an eye for beauty—have told her that she will soon go completely blind. Of course, she was very upset by the diagnosis and evoked fear regarding her ability to cope with the future, but since then she has begun to prepare accordingly and to train her other senses. Beauty remains and continues to have an effect and as everyone knows, one only sees beautifully with the heart.

10 Conclusions

In contrast to traditional forms of therapy, confrontation with the beauty requires much more of an encounter at the eye level. Value discussions with addicts must be carried out very sensitively, as alcohol-dependent persons are very severely affected by guilt and shame at the beginning of therapy. Self-devaluation and mental or sometimes physical self-harm are dysfunctional coping strategies for the preservation of the self. If the therapist begins to offer the beauty too quickly, it is usually not accepted or becomes the object of devaluation. The therapist’s task is, therefore, to create situations that make a deep experience of the beautiful more likely and, if that has actually happened, in support to make the beautiful an integral part of one’s personality.