This work describes an experience at San Filippo Neri Hospital in Rome. It is the result of a collaboration with the Department of Neurosurgery and the Psychiatric Facilities DSM-RM E within the hospital, and is one of the many activities that are carried out by Psychiatric Consultation of which I am in charge.

We are talking about a group psychotherapy that meets once a week, over a period of ten weeks.

The four members (two girls and two boys between the ages of 18 and 22) had been operated in neurosurgery for cranial trauma. They had all suffered from post-traumatic coma sometimes drug-induced. They were recovered in Intensive Care for several weeks, and suffered from cognitive-behavioural deficits but not neuro-motor deficits. This group could be defined as being a “short term” “homogeneous” group, in as much as the patients all suffered from the same pathology. The two technical modifications that denote this experience with respect to a classical group therapy, is the introduction of a psychotherapeutic instrument in a group of patients affected by ‘organic’ pathology that apart from a generic request for support in order to overcome the traumatic event that they had suffered from, had not made a formal request for this type of treatment.

The purpose of forming this group was not to bring about cognitive rehabilitation, but rather to encourage affective integration after the emotive experience consequential to the trauma and recovery in Intensive Care.
The group was analytically conducted by the free associations technique, with particular reference to Soavi and Bion.
Soavi’s ‘procedural’ notion regarding the unconscious memory (Soavi 1996 & 1999), and Bion’s concept of the “protomental” were both utilized.
Soavi, an analyst who practises individual analysis, holds a prominent position among those analysts with avant-garde ideas in the psychoanalytical world who observe with interest and attention the recent advancements of the neurosciences concerning the functioning of the human brain. Soavi believes that our affective responses are not separate from our bodies, but are deposited in complex neural nets in each individual from birth, or even in the intrauterine state, and are adapted or regulated by the mother-child relationship.
Some procedural patterns seem to be strengthened and therefore selected by gratification or success within the relationship with the mother, whilst others are abandoned.
It seems that these patterns are established by the procedural memory, which is unconscious and is connected up to neurotransmitter, endocrine and neuro-vegetative activities, it differs from the declarative memory that can reactivate memories consciously.
Furthermore, Soavi hypothesizes a “Parallel Distributed Processing” where a psychic symptom or a somatic symptom is produced when conflictual circumstances occur during the course of life. The production of one of the two is related to the memorized procedure that came about previously when a similar difficulty came up in the primary relationship with the mother and depends on which one was most successful.
On the other hand, by protomental, Bion means an internal level in which the psychic and the biological are in an undifferentiated state, “they are the same thing”; here we are talking about a basic level -the beginning of any future affective development or thought that belongs to the individual. The protomental is above all active from the very origins of life, where the body ego and the psychic ego are superimposed. In very early childhood the baby is emerged in a sensory world and only with the mother’s interpretative capacity will the baby start to organise and then with growth connote diverse and perceivable emotions, above all the baby will establish specific affective and relational modalities for the future, for its adult life.
Bion believes that the functioning of this level can be seen easier in collective or group situations, and the observation of a group could be very useful in researching psychosomatic pathologies: “If only we could convince 30 people with rheumatic pain to meet together, we would learn something…. It’s very likely that the group process could tell us everything that our entrails already can tell us – hunger for instance – is something that we know very little of, cognitively.” (Bion,1976)
Since the protomental is a level where the physical and the mental are undifferentiated, “ so now we understand the reason why, when a sentiment of anxiety arises it can reveal itself either in a physical form or a psychological form”. (Bion,1961)
Therefore in important conflictual situations, it is on this level that the suffering orientates towards the production of a psychic symptom or a somatic symptom.
Likewise the group through a process of synchronicity of the protomental and procedural states favours the production of signs at different levels, either on the somatic side or on the psychic side.
In particular, Bion says, “starting on the level of protomental phenomena we can say that the group continues to develop until the emotions can be expressed in psychological terms,” (Bion,1961). In this way the constitution of the group mind (gamma function) allows the transformation of sensory and rough elements (beta elements) into narratable emotions.
In the same way I believe a group with organic patients, homogeneous because of the existing pathology, gives the members the opportunity to live through the somatic-psychic experience that they had previously undergone.
In this particular group of patients with head injuries conducted by me, I will try to illustrate how the somatic and sensory level of the experience linked to neurosurgery, coma and recovery in Intensive Care came about and how it allowed the expression and sharing of an experience extremely charged with anxiety of death, but above all how it gave the members the possibility to relive the experience dissociated from what they had suffered.
The warm reception of the group leader and the containment of the group allowed the group to transform unconscious experiences into the images of their dreams, which as we all know have the function of uniting imperceptible, sensory and corporeal phenomena (elementi beta) to the phantasmatic life of the individual or the group, providing usable images and organising perceivable emotive constellations.
In my experience I’ve observed that organic patients have the tendency to dream and narrate somatic issues, in this way a “central phantasy” prevails regarding the personal experience or the collective experience of that particular illness.
In this particular case the members of the group were coming to terms with the end of the developmental junction, and it seems separation anxiety produced acting out, hence the accidents they procured themselves – a break down was acted out on the body. Thus an element of concreteness pervaded the group that was not easy to elaborate.
Carbone (2005) affirms: “The trauma is in a mnestic space that cannot be defined as memory or repression. It cannot be remembered and it cannot be forgotten.” -thus indicating an affective overcrowding that overcomes the integrative capacities of the experience of the Self. This type of situation demands a different technical disposition on the part of the group leader. In these cases Privat suggests a certain elasticity in order to get back to specific thought in certain processes that are “blocked by excitement”.
Different materials or games are used for children’s groups, in my case the group accepted to work on photos.
Privat affirms in the initial phases of a group, especially in groups where narcissistic pathologies prevail or in certain processes where prevalently a modality of archaic relationships has been activated, the therapist must pay a lot of attention to the constitution of the container “ the para-excitement” encasement as he calls it. He goes on to say: “…we think it’s important that the phantasmatic Oedipal issue is not touched on until the group is not cathected as a good object, seen as a place for restoring oneself and for narcissistic gratification….then we can speak about the transference on the group, phantasized as an omnipotent mother that gives one and the same to everyone” (Privat,1996).
On describing this experience I will list the points that I consider most significant. One of the girl participants in the first session said: “Waking up from a coma is like being reborn in a body in a worse condition, you are yourself, but your body doesn’t belong to you”.
The participants rapidly started talking among themselves, quickly gaining familiarity -a successful attempt to furnish the mental room of the group had begun.
Daniela (hit by a car) is blind in one eye, suffers from headaches, she doesn’t feel like going out anymore and lacks interest in anything.
Alessandro, (involved in a car accident) has problems following the movies, he complains they go too fast.
Sara, (a fall from a horse) has had memory problems for the past months, at present she has difficulty with her studies, especially with concentrating, she has to repeat for hours.
Daniela, also has difficulty in concentrating, then she asks the others if they have sense of smell, she adds she has no sense of taste.
Fabrizio, (punched in a brawl) has a too highly developed sense of smell.
Sara says since she lost her memory she doesn’t feel the same, she doesn’t feel emotions; she reads the love letters from her boyfriend to see if she can feel something: she says the letters are the same only the emotions are lacking.
Alessandro complains that since he was ill he is unable control his temper, he has fits of unrestrained anger. He also suffered an epileptic attack. He proposes to face the situation “eye to eye”, perhaps answering Daniela who lost the sight in one eye, and encourages everyone to get in the perspective of compensating the coma (the blind eye) with the resources that are being offered at present.

The first session ends with the promise among the participants to bring photos of themselves taken before their accidents.

The photos in the following session show Alessandro posing in the guise of a “tough guy” next to his car: Daniela shows more than one photo, “when I was pretty” she comments laughing, her hair was long then and a different colour; Sara’s photo shows her 18 th birthday in a restaurant with her boyfriend, she is dressed elegantly and has long hair; Fabrizio has forgotten to bring a photo.

The presentation of these photos generated intense emotion and an immediate sense of fracture; for instance Sara’s very short hair is unable to conceal the hollow in the top of her skull, she wears only sober clothes now, always choosing the same blue like a secular nun. The fact they were allowed to bring something personal even though it was in a flat bi-dimensional form, gradually allowed them to convey emotions and experiences that the trauma up to that moment had solidified: the photos are passed around, their eyes avidly caressing the photos, expressions of surprise are followed by cheerless silence. Their reactions are not always speakable, but at least they are shareable.

A previous group conducted by me with women affected by mammary neoplasia comes to mind; in one of the first sessions long before these women were able to speak about the emotive impact the disease had on them, they revealed their breasts and reciprocally felt their scars (Bruni S.,Marinelli S.,Baglioni L.,1999).

In my opinion, the gradual progress towards emotional development and the symbolization of the underlying experiences is facilitated by the acceptance of concrete modalities of communication through the senses in groups, especially those groups that have gone through extreme experiences.

Alessandro produces the first dream: he is with a friend in a caffe’-warehouse, where there are also some girls. He starts touching their breasts but is amazed at their friendly smiles. This dream facilitates an associated chain where in particular, the theme of solitude and incapacity to communicate the period of darkness are unveiled: bonds between couples are starting to collapse, or it’s almost impossible to start a new relationship, no-one is able to understand the experience the members have gone through and for them is still unspeakable, is still “without a name”.

The dream recounts the possibility of a gratifying contact: the girls aren’t angry, indicating an affective cathexis on the work-group, perceived above all as a primitive source of gratification; the breast seems to be primally experienced as an altruistic organ of maternal nutriment rather than a conflictual object of erotic attraction. The possibility of a trustful abandon to experiences that probably will never be verbalized is expressed.

The importance of a disposition to accompany the flow of unspeakable experiences to enable an affective progression for all the members of the group is also sustained by Neri when he writes: “…one could refer to this as an experience “without-form”, “without-limits”, “without-order”, a “non-defined”, or a transitory experience. I am referring to the essential elements that make “a loosening up” possible, in order to reach that state of quiet from which a creative action can arise” (Neri 1996).

In the following session, Alessandro exclaims: “… at last one can speak without problems, I have the sensation there are one hundred ears poised to listen…” indicating the constitution of a single group-mind equipped with a collective perceptive apparatus (the walls are covered with ears) to record the sensory and emotive life of the members. The group seems to have acquired its own apparatus for thinking thoughts.

The solidity of the group is now guaranteed and the members’ acceptance of an atmosphere of anxiety and sorrow allows them to abandon themselves to sharing the most painful of themes: for instance, the recovery in Intensive Care and the people they have witnessed dying, the risk of death, suicidal thoughts, anger and mental suffering for the limits imposed by the illness, on one hand complete disinterest for life and on the other, intense youthful desire for the right to live it to the full.

In the next session, Sara brought a dream about her recovery in Intensive Care. Sara is in a hospital bed and tells the doctors on the left side of the bed that she is going to give birth to two big black spiders and two little ones. The doctors tell her to ask help from the fishermen on her right side, outside the window. A fisherman takes her into the desert to give birth. She throws back a blue blanket and gives birth. She adds: the spiders make her think of bad things. The group comments the dream, enhancing the many confused moments in Intensive Care, the disorientation of time and place, the solitude and the sensation of being at the mercy of the events. Daniela confusedly remembers her state of agitation when she woke up and an irrepressible need to eat something.

Sara’s dream refers not only to herself but the family of spiders refers to her own family, that perhaps she links up to her accident, and the spider-like bruises she got from it, (Sara’s parents were preparing to separate when she fell off the horse and she was particularly anxious about it). The dream also tells us that the group could give birth to its “black” depression linked to the experiences that accompanied the illness, moreover this dream facilitates the expression of the quality of the experience of certain states of conscience alteration in Intensive Care, probably linked to different phases of waking up from the coma. The dream is composed of internal perceptive elements but also external, for example, the doctors and the blue blanket, all seen in a sort of hallucinated, crepuscular, uncontrolled, anxiety-fraught deformation of the surrounding reality.

The effects of the group work are starting to be seen in the quality of the dreams, and also progress towards a change in the emotive atmosphere and the integration of split experiences comes about, like those felt concerning the superficies of the coma experience unable to be communicated up to that point.

Sara brings another dream that recounts of a prayer she is making in a church, when her boyfriend arrives with another girl. She recounts of a wedding between the scout leader and his present wife. Her scout leader becomes her fiance’ and she arrives in church in a bridal gown only to find another bride. She runs away in shame excusing herself, and then she goes home. The bride’s parents arrive and demand an explanation Sara says she’s sorry.

Sara’s comments everything she does is much slower than her boyfriend.

This accurate dream tells us that Sara is a bride but at the same time she is not a bride, and she excuses herself for thinking it; she is not the protagonist of the scene, it does not belong to her anymore, and she runs away ashamed.

This syncretic image can tell us more than any words can, first of all it brings to the fore the intense participation of this suspension from life and the dramatic sadness that is caused by it. The experience of the coma is relived and shared, and renamed in an affectless and reassuring context thanks to the therapy.

Furthermore, this syncretic image allows us to bring to light an expression that we call the “central phantasy” in this group of patients with head injuries: they had all experienced a situation between life and death, their state of consciousness had undergone an experience of deformation and suspension dissociated from their own existence and everyday life.

To sum up, this dream tells us about the progress of group work. Sara, for instance, who at the beginning introduced a photo of herself and her fiance’, and was sleeping with an old photo so she could recognise herself on waking, has re-established herself in her internal world, she moves in a ‘tri-dimensional’ space offered to her by the group container, managing to narrate about herself, for herself and for the group without neglecting her own mental suffering.

This arduous period of going through a situation of non-sense and non-place, is similar in some respects to that ineluctable developmental junction that we call adolescence.

Before the group started the members’ parents and the group members were often ringing me with various problems, after the group had terminated, I never heard from these patients again.

I believe this is an important sign. It means, in my opinion that the experience was sufficient to satisfy the need to be listened to of these young people and above all favoured a mise en scene of emotive force that interested them very much. Perhaps, just as we do after a period of mourning that is not split or denied, so the members of the group were finally able to take up the course of their lives.

On concluding, the leave-taking in our final session comes to mind: Sara speaks briefly of the circle around the fire at scouts’, the physical contact is associated by the members, the pleasure of being together, the childrens’ game, ‘ring-a-ring-a roses’ is evoked: a circle is the first graphic sign, it is the first image children make of themselves and it represents the first corporeal Self (Gaddini 1981).

The atmosphere is intimate and warm, awareness of the shared experience emerges and also perhaps if not fully, the perception of an integration of the experience of the body even though badly scarred: hence, the circle.

Furthermore, the experience of the body and the trauma in a group of young people assumes an important evolutive value for the future development of the identity.

BIBLIOGRAPHY

Bion W.R.(1961), Experiences in groups, Tavistock Publications, London; Trad.It. Esperienze nei gruppi, Armando, Roma 1971.
Bion W.R.(1976) Interview with A.G.Banet jr., Group and Organisation studies; Trad.It. Intervista con A.G.Banet jr. in Il cambiamento catastrofico, Loescher, Torino 1981.
Bruni S., Marinelli S., Baglioni L.(1999) “Sogno, corpo e malattia nel gruppo” in Sogno e Gruppo, Funzione Gamma, n° 2 http://www.funzionegamma.edu/magazine.
Carbone P. “Il disturbo post-traumatico da stress in adolescenza” in ‘Manuale di psicopatologia dell’adolescenza’, Raffaello Cortina, Milano 2005.
Gaddini E. “Note sul problema mente-corpo” in Rivista di Psicanalisi, XXVII,1, 1981.
Neri C. “L’assetto mentale dell’analista al lavoro nel gruppo” Koinos n°2, 1996.
Privat P. “Proceso gruppale, processo di pensiero e interpretazione nei gruppi psicoterapeutici di bambini” Koinos n°2, 1996.
Soavi G.C.(1996), “Motivazioni e operare clinico” relazione scientifica al Centro di Psicanalisi Romano (non pubblicato).
Soavi G.C. (1998), “Memoria procedurale, regolazione interattiva e psicosomatica” Medicina Psicosomatica, 43, 51-58.

Summary

A short-term homogeneous group of young patients who experienced cranial trauma and recovery in intensive therapy is presented.

Once the somatic and sensory experiences triggered off by the trauma and its treatment were mobilized in a group experience, elaboration and transformation of unthinkable elements into emotional, recognisable and narratable elements came about.

Key Words: Group, cranial trauma, altered states of consciousness, procedural memory, protomental.

NOTES

(1) All quotations in the texte are translated from Italian language

The author, Simonetta Bruni, Psychotherapist and Psychiatrist, works at the Psychiatric Diagnosis and Treatment Centre, ASL RM E, ACO, San Filippo Neri Hospital, Rome.

E-mail: bruni.simonetta@tin.it

Translated by Deberah Catts Petrini

N.T. translated by the translator