Introduction

This is an account of a Brief Analytic Group Psychotherapy experience with patients with chronic renal damage who were being dialyzed while waiting to receive kidney transplants.

This practice was carried out in 1997, in the Psychiatric Liaison Unit of the Psychiatry Division of Hospital El Salvador , in Santiago , Chile . The authors had the chance to observe, on the one hand, the transplanting team's and hospital patients' demands for psychological help and, on the other hand, the difficulties said Center's psychotherapeutic team encountered in serving such demands.

In this context, and being aware of the effectiveness of the group psychoanalytic approach, the writers undertook the challenge described below.

Obstacles and Difficulties: Form and Substance

Of the difficulties encountered, two were present from the beginning. One was the limited time availability, which the therapists resolved by adopting a brief, dynamic, group psychotherapy approach based on Nacher and Camarero (1995).

The feasibility of doing brief therapies was confirmed with W. Piper (1995), whose experience in working through mourning in twelve-session therapies with patients having experienced difficulties working through the loss of one or more objects was known to the writers.

For the sake of brevity and the emphasis we wish to place on our clinical experience with this particular group of patients, we will not enlarge on what could be an explanation of why group? and why brief? In principle, we would just like to point out that many authors agree that, in group therapies, role awareness processes may be accelerated based on our understanding of the multiple transference concept, of which, by alluding graphic images, it might be said that "individual analysis is a mirror you need to place in various angles in order to be able to see everything, while group analysis is a room entirely lined with mirrors, in which you see yourself reflected everywhere you look" (Grinberg, Langer, Rodrigue, 1959).

The second difficulty that seems important to us, as it jeopardized the achievement of our assignment, might be understood as a loss of prestige of the psychological within hospital culture which we understand as a decline in the significance of the doctor-patient relationship, with a bias towards the stand of dividing the human being into parcels -which has been a conflictual subject in numerous hospitals. Its resolution would aim at a cure that, as Parada (1997) puts it, takes into account "the suffering person," and not only the body as the sole field of interest.

We could see the above posture reflected in statements made by medical and paramedical staff members. At the first preparatory meeting with the Transplanting Team, for which we had had to wait a long time, we were informed that the room to which we had been summoned was being occupied by a "more important", meeting of a medical nature. On another occasion, someone suggested that the therapy take place during the patients' dialysis period, because "some of them got so bored, this would help them pass the time".

Similarly, prospective members of our group of patients were told that they needed to attend some "lectures" about transplants in order to be eligible for the operation.

All of these statements, often well-meant in the conscious domain, showed us the likelihood of the existence of an unsolved unconscious conflict concerning our assignment, where on the one hand, in a medical field the need for psychological help arises and on the other, devaluation appears.

According to Liberman (1976), this kind of communication would contain a pragmatic dominance disturbance (a communication disorder characterized by a lack of symbolism, where language is used as an action). 3. Working Hypothesis: The Oneiric and the Regressive in Group Therapy

The information we possessed about our homogeneous group of patients was that they displayed a high incidence of depressive disorders. This condition would appear in the period when the patients had to undergo dialysis while waiting for kidney transplants. After the operation, there was a tendency for patients to repeat the depressive symptoms, which surprised not only the medical team but also the patients themselves. The Transplanting Team's common sense understanding of this post-transplant depression was explained via varied hypotheses, the one that came in handier being: "Patients get used to functioning as children, to being permanently taken care of, and to having someone else do everything for them. Subsequently, it is hard for them to go back to being independent."

Our basic assumption was that we were dealing with a group of patients traumatized by the many mourning processes they had experienced, starting with the loss of their renal function. Before long, a sequence of losses labor, affective, social and others- unchain, owing, among other reasons, to the patients' reduced useful time. This ends up in isolation, which entails the loss of their support networks and, ultimately, their living projects.

We believe this particular group of patients was already in a regressive condition by the time the therapy began. We may consider this condition as regression to extreme dependence, with the concomitant anxieties, fantasies, and defenses. This was obvious from the kind of relationships these people established with the objects forming the world of dialyzed patients, e.g., doctors, nurses, paramedics, and dialysis machines.

In other words, regression portrays a phenomenological occurrence in subjects in general, but in this particular group, it operated as a way of defending from and at the same time adapting to internal and environmental drive realities. In this group, both were plagued by new, overflowing requirements.

To Freud, "dreaming, in the aggregate, is a regression to the dreamer's earliest condition, a revival of his infancy, of the throbbing tendencies that used to govern him and the modes of expression that were available to him at that time".

Another source of reference (Gallo Mezo, 1998) tells us that the regressive process unleashes the prevalence of figurative and syncretistic modes of expression that are comparable to dreaming, albeit not delusional.

Furthermore, Freud thought that dreams not only express individual biographic data, but also show the most archaic conditions of mankind, by collecting the primeval phases of the history of mankind, using the Darwinian theories of the primitive horde, contributing new developments to the psychoanalytic theories of the paternal figure, of oral incorporation, of identification, of guilt, of the symbolic dead father, of religious theory, etc. (C. Silvestre, quoted in Gallo Mezo, 1980).

Then, considering the relatedness between regression and dreaming, we may posit that the regressive and the oneiric cross these patients' life experience.

The extreme dependence generated by the fact of being connected to a dialysis machine, that implies fighting for life and dreading death, and evokes the early stages of development as described by M. Klein, may be conceived as a dream in which latent contents with great amounts of persecutory anxieties appear, which are subsequently disfigured in the oneiric manner, through markedly idealized, manifest contents placed on the medical team, on the machine, and then, precociously, on the therapists at the beginning of the therapy.

We understood the above as omnipotent defense, and interpreted it as "the mask" that disguised the patients' deepest anxieties, as we shall see later in this paper.

Our work focused on the attempt at working through this "dream" by making conscious what was latent in the patients' manifest reports, which led to the finding of archaic, and therefore pretty dreaded, fantasies.

Following Bion's lead, we think a psychoanalytic group is established at the time when the individuals forming the group are all in the same regressive condition. In the group we are describing, this was observed spontaneously and from the outset.

This may evoke the time when the baby requires, for its development, the function of a containing mother capable of performing a reverie function, as described by Bion.

We think these patients may give the dialysis machine the meaning of a detoxifying mother but, in this state of extreme dependence, a set of pretty primitive anxieties would be generated, which are not metabolized and might unchain various psychopathological processes, leading even to rejection of the transplanted kidney.

Our task, therefore, should be an attempt to make this mental detoxification possible from a therapeutic position that facilitates a containing environment permitting the flow of schizo-paranoid and depressive anxieties.

Concerning group psychotherapy, Ganzarain (1995) indicates the existence of different theoretical-practical trends inside and outside psychoanalysis. Furthermore, Sandler (1983) believes that psychotherapeutic practice is often based on a theoretical position that frequently remains implicit.

Freud's, Klein's, Bion's, and subsequent authors' contributions support our particular training. Thus, as Parloff (1968), we successively combine interpretations addressing the intrapersonal and the interpersonal, with those embracing the-group-as-a-whole, in a non-exclusivist approach, and when we do so, following Davanzo (1998), we understand that this is a way-station in the recurrent work of interpretation and the working-through process, stressing the insight that determines a common denominator between the contexts of current external experience and childhood experience with its genetic contribution.

When this "linking pattern" is enriched through the impact of transference interpretation, i.e., what has been experienced in the "here and now" of the session, it helps to avoid intellectualization.

Somehow, our work consisted in giving new shapes to what broke into, overflowed, arrested mental growth and obstructed the achievement of greater linking complexity (Pujet, 1996).

4. Development

We gathered eleven patients, two of which abandoned the therapy from the second session because of "changes in their dialysis schedule." In the first session, we stated the duration (14 sessions) and the rules of the therapy, encouraged the patients to freely make known everything concerning themselves and the others, and asked them to introduce themselves: "Who I am and what is happening to me". Our interpretations, including the relational ones, were focused both on the individual and on the group as a whole. (H. Davanzo) The procedure was co-therapy, and there were two observers, both of them female intern psychologists. The manifest contents expressed in the first session showed an idealized dialysis.

The patients strove to show their therapists and mates how quickly after their first dialyses they had started feeling better and how they had no problem with it because, "without dialysis we would be dead." Moreover, they reported being treated with care and kindness. Other statements made by the patients revealed the foregoing: "I came back to living when I started having dialysis," "You may eat anything before dialysis; anyway, the machine takes over," etc. No negative aspects were mentioned in this session.

In the second session, something different started surfacing, which led us to think that what had happened previously was related to the need to deny the painful psychic reality that conceals highly primitive latent contents.

As we shall see over the development of this communication, this dialectic game of resisting the emotional experience on the one hand, and desiring it on the other, is always present. We might conceive of it as the permanent game of oneiric disfiguration that prevents unconscious thoughts from moving toward consciousness.

Resuming the second session: After a long silence, some subject-related trends emerged, such as appearing before others as if wearing a "mask", same as with dialysis: "You cannot show or tell your family what is happening to you, they would collapse."

The foregoing is seen as an "attitude" that gradually vanished and was repeatedly pointed out and interpreted, and consisted in "showing yourself to the other patients and the therapists with a polite smile, as if nothing were happening, nothing were tormenting you." Then, gradually, the state of confusion became apparent, as a defense against experiencing psychic pain.

The foregoing is linked to the flight from underlying fragmentation anxieties.

For example, a female patient said: "I don't have any problems, because I just trust in God," and then showed her arm, deformed by a fistula, with utterances denoting her rage at this condition, and then puts forward contents such as "the fistula hoax."

Later, a group conversation about how they related to the dialysis staff took place, with remarks such as: "I always bring small gifts to the nurse," and then: "sometimes I cannot bring her anything and she stands there, as if waiting for it, with a surly face."

Another patient interrupted to say that the nurses were very thoughtful, and immediately reported that sometimes they placed patients anywhere: "They place me near windows, exposed to air currents; they don't give a damn if I catch pneumonia." We interpreted the above exchange about the dialysis staff, in the transference, after an account by a female patient which turned out to be useful in understanding what was transpiring deeper inside.

The patient said the following had happened to her once: "I was having dialysis and I thew up all the lentils, which were scattered everywhere."

We interpreted this as her fear of expressing in the group her objections and emotions, that were felt as vomit, as she ignored whether the therapists and the other patients would tolerate them and take them in. We phrased this interpretation repeatedly, in various ways and on different occasions, in view of group resistance.

After hard work, a young member of the group, a man almost in his thirties, came up with the idea:

"I don't have to be grateful to anyone, there is no reason why I should make their (doctors and nurses') lives pleasant."

"I admire her for thanking God, because the first thing I lost was faith. I used to be pretty close to the Church in the past, but now I have not stopped crying a single day since I was attached to the machine. You never accept it; nobody could ever accept it. It is going to be hard for you to understand this; you would have to be in my shoes. I think no one can be unconcerned, after this my life changed."

We interpreted this as fear of what might happen if they got attached here, to the machine-group: How would they come out? Would they benefit from this or not? Or rather, would a painful experience that might remain camouflaged by a smile or seeming good humor be repeated?

We also interpreted, would they be able to "throw up the lentils" without us getting scared at these contents coming from their insides? Or would the therapists be qualified to understand their contents, if they "were not in their shoes"?

The young patient answered affirmatively, and the rest of the group assented quietly.

We thought this was important. In Claudio Neri 's words (1995), "What has happened here is an effective relation or report (our underlining), namely, a narration capable of establishing direct contact with the audience."

This patient added that he had lost his job and broken up with his fiance, "because I didn't want her to be with me out of pity." "I came to therapy because my parents asked me to do so; I came to give it a try," he adds, "because my parents feel pretty nervous for me all day long, they treat me with pity, which I hate! I think you (addressing the therapists) will not be able to understand this."

The other members of the group confirmed the above statement either verbally or by nodding their heads.

Then, in a different emotional atmosphere, a discussion of the fears, the anxieties, the loneliness caused by this condition, and the need to have a chance like this to "vomit the lentils", followed.

The latter emotional moment was linked to the idea of a germinative status of the group a concept of Foulkes' that means approaching the group with the image of an ovary in which numerous egg-cells are present, and the image of a germinative soil.

This concept evinces the germinative group dimension and containing nature, inside which those elements that had not yet been individualized could take shape (Foulkes, 1995).

It seemed to us, however, that Parthenope Bion Talamo's remark (1995) concerning work force mentality and primitive mentality which are expressed as co-present, opposing instances- gave a better account of the motions manifested in these first sessions, since together with the appearance of the basic assumptions particularly that of dependence, which will span the therapeutic process, and that of attack and flight- the rudiments of collective thinking about what "getting attached" to the dialysis machine and "getting attached" to the Group would mean.

These rudiments of collective thinking marked the progress of the therapy, where the transference model of the-group-as-a-whole was developed by relating, in the first place, to the therapists as a dialysis machine that, in addition to helping, could damage them.

This paranoid fear was hidden before both the therapists and the staff of the dialysis unit, because of retaliatory or revengeful fears.

The amount of aggression in these deformed perceptions comes from the anger raised in them by the extreme dependence on a machine-mother-therapist, that activates early anxieties from the paranoid-schizoid position.

This was of interest for the purpose of understanding this group's process, as it shall be seen in session N°10, on Chris tmas Eve (December 24), where fantasies with a persecutory hue, associated to the core anxiety that best represented this particular group of patients, emerged and were delved into.

The session characterized by a meager, below-average (seven people) attendance.

We interpreted the above as non-verbal communication of contents that might be too hard to express. This was plainer when associated to direct requests made to the therapists not to suspend the therapy on the eve of holidays, because to the patients, these days were "just like any other day."

A patient answered for the group, saying: "well, there are many accidents on holidays, maybe they didn't come because they are in their homes, waiting to be called up." (Meaning waiting for a donor.)

The group answered with giggles and horrified facial gestures.

We interpreted this as follows: "It seems that what is hard for you to talk about with regard to this waiting period, is the desire for accidents to occur in order to have organs for transplant."

After a silence charged with emotion, we interpreted that "it seems that the intense desire to find this organ makes you feel guilty of any accidents that may occur during this holiday".

A female patient answered, "Oh! we had never thought about it, but I do imagine some hyenas waiting for their preys."

Another patient concluded, "You've got to go on living, some people donate their own organs while they are alive, in other cases, their relatives do, and you can keep seeing them afterwards and maintain good relationships with them, so I don't know what the big deal is, I fail to see the problem."

We interpreted this by stating that "it seems that needing and wanting a transplanted organ to be able to go on living makes you feel like hyenas, like greedy animals, rather than human beings."

After a long silence, we interpreted once more, "It seems it is hard for you to integrate the natural desire to stay alive, to preserve life, and therefore wish for organs in Chris tmas time, because this makes you fell guilty before family members, donors, and kidneys, and this shows in your desire to endear yourselves to them and thus, like hyenas, keep the "giggles in the middle of the banquet."

Another patient added, "I do not know, I think you have a right to live, I feel this is just like with those Uruguayans in Los Andes, do you remember? They had to eat their friends in order to survive." This was followed by our interpretation: "It seems that, although the kidney is incorporated via surgery, you can live it as devouring another human being, and you can feel this as if this organ inside your bodies would take revenge and attack you."

Somebody replied: "I had never thought of it, but this is the most important subject we have talked about in this therapy." Someone else added: "Yes, but it gets to my nerves, it scares me."

Moving in another direction, another patient stated: "I think you can take the kidney as a baby, you have to welcome it and take care of it."

We said that their difficulty to lovingly receive the baby-kidney is a result of the guilt brought about by their inability to differentiate between the legitimate desire for an organ and the magic attachment of this desire to the guilt about someone dying because of this desire.

Silence was the answer, and we ended the session by interpreting the difficulty to nestle the kidney as a beloved baby when guilt of a magical nature appears.

The session ended in an intense but very close atmosphere.

In our view, the above material shows three moments where thoughts and enactments are expressed that are highly rejectable by an individual under oneiric censorship, namely, the scenes of the lentils, the hyenas, and the Uruguayans.

From a dreaming standpoint, these scenes reveal a primitive, syncretistic group thinking, the foundation of which would reveal oral regression. When this is interpreted and, therefore, moved from the repressed to the conscious, a possibility to symbolize is attained.

In Matte Blanco's words, the progress from an asymmetric, unconscious, oneiric logic to a symmetric, Aristotelian logic typical of the conscious domain has been achieved.

In the last three sessions, the feelings linked to separation and their concomitant anxieties were worked through. Here, the therapists appear attached to cold, egoistic images, as we would not be interested in the patients and their problems but in science and our personal accomplishments.

We interpreted how difficult this separation is and how said difficulty may be related to our "metaphorically feeling like transplanted-rejecting organ-therapists who don't want to continue to nest in your minds and don't want to continue to detoxify you from your strong emotions."

A silence full of meaning followed.

Once more, we interpreted: "It seems that in your minds, together with the previously mentioned painful feelings, is the hope for this experience to have been like a good transplant, and for us to nest in your minds for a long time!" "And maybe for ever, helping you to accept and clean out many emotions that are normal and common among people living in your circumstances."

After a silence, a patient stated: "I think this therapy has been very good to us. Nobody had ever listened to us as you have. This should continue to be done."

Another patient added: "You should discuss it with the director or propose it to the Minister of Health."

Then, another patient added: "I want to say something that may be irrelevant, but it is true, something like a gap will remain, a space we will need to fill. For example, that day when we did not have the therapy, I went to renew my identification card!"

Somewhat moved, we took in the patients' difficulty to separate, and stated that there was a desire to continue but, at the same time, the group felt as if they had got new ID cards, new identities that had been disguised by this illness.

A deep emotional atmosphere filled the room, and then laughing secret talk between a male patient and a female one followed.

When asked to share this, the woman told she was trying to find out whether this male patient had accomplished what many times, jokingly, the group had asked him to do as homework. This consisted in having intercourse and then telling the whole group how he had done. After much laughter and another emotional silence, we interpreted:

"Apparently, your illness is no longer felt as a hungry hyena that takes

everything, even sexual desire, away from you, and now you can recover your condition as persons with a wide range of feelings and wishes that now you are better prepared to accept and nestle inside yourselves."

Conclusions

The reported experience permitted us to observe in these patients that the loss of the renal function is also accompanied with loss of mental functions.

We think this is a result of regressions to archaic stages of the psyche, such as primitive idealizations and magic thinking, which make the idea of the transplant to be experienced, at more unconscious levels, with terror and persecuting guilt.

With regard to the matter of our interest, we can understand the material from the sessions as oneiric representations, which at the beginning of the therapy are intended to disfigure unconscious representations and thoughts that are censurable to the group mind.

In other words, the dream of having a transplanted organ, as a manifest contents at that stage, disguises latent contents and oneiric thoughts that are removed when linked to ontogenetically and philogenetically primitive aspects.

To the individuals and to the group mind, it was degrading to make contact with this emerging material, and narcissistic defenses were triggered.

Thus, our work focused on the attempt to work through "this dream" with the group and the therapists in their containing aspect making it possible for such primitive material to emerge.

The emergence of these unconscious representations and thoughts is based on the desire to live and on the fear of death. These patients' day-to-day is permanently exposed to the recollection of anxieties linked to very early stages that enter their psyche like day residues.

Additionally, we were able to observe the state of isolation and loneliness these patients progressively get in, which makes them lose any authentic communication with their loved ones and their social environment.

They take refuge in regression to extreme, idealized dependence on dialysis, which they invest with magic thinking as if it were their lifesaver, just like the kidney they are waiting for, a waiting that is lived with extreme passivity. We think this regressive process turns them into suffering bodies devoid of the wishes and emotions typical of any human being.

Our work gradually focused on the recovery of the person, the subject who, though dependent, is also the possessor of liberty and of the ability to feel and think, which cannot be given by the dialysis machine or the kidney, but by someone else other than him- or herself.

This therapeutic process is achieved in a containing atmosphere that makes mental "detoxification" possible through the dialysis machine-reverie function mother-therapists. This is how the most terrifying fantasy could arise in someone expecting a kidney:

"Feeling like hyenas, voracious animals desiring the death of another one in order to be able to survive." This is lived in fantasy in a magical way where the experience is of oral, cannibalistic incorporation, with the resulting object destruction and fear of retaliation. Thus, not only persecutory guilt producing potential psychopathological conditions such as the depressive symptoms mentioned above, but also a psychological difficulty in being able to receive a transplanted organ, which might result in postoperative complications and eventual rejections of the organ. The working through of these fantasies and the concomitant working through of therapy-termination mourning, permitted these patients to move to a more realistic, authentic position, and be able to accept demands for psychological help, and they got to assume their own abilities, values, self-esteem, and rights, which they had lost together with their renal function.

They also dared to appropriately express anger at the termination of this experience, and their needs and desire to get much more help.

This work was developed in the context of a strong therapeutic alliance and in a close atmosphere that, to the therapists, constituted an actual emotional experience in the encounter with these suffering minds that, as Gerardo Stein (1991) puts it, "helping to discover the unconscious of the other, and taking advantage of someone else's help in order to discover something belonging to one's own self, is a task that transpires in the day-to-day in every relationship where the ethics of love for the object prevails over the ethics of love for power." (Our underlining.)

We would like to conclude our presentation by quoting Freud: "It seems that dreaming and neurosis have preserved for us more from the antiqueness of the soul than we might suppose, so that psychoanalysis may demand for itself a high rank among the sciences that endeavor to reconstruct the earliest and most obscure stages of the onset of humanity."

(Freud, 1900)

Antonia Staforelli Mosca, Psychologist

Analytic Psychotherapist

A Candidate at Instituto de Psicoanàlisis de Chile .

A regular member of Asociaciòn Chilena de Psicoterapia AnalÌtica de Grupo

Address: Pablo El Verones 832, Las Condes

Santiago , Chile

Telephone number: 56-2-228-8687

Fax number: 56-2-342-1132

E-Mail: HIPERVÕNCULO mailto:astafore@ctc astafore@ctc internet.cl

Luis Suàrez Gaensly, M.D., Psychiatrist

Analytic Psychotherapist

Full Professor, Group Analytic Psychotherapy Dept., Universidad

Internacional SEK Chile

A Candidate at Instituto de Psicoanàlisis de Chile

A regular member of Asociaciòn Chilena de Psicoterapia AnalÌtica de Grupo

Address: Pablo El Verones 832, Las Condes

Santiago , Chile

Telephone number: 56-2-263-6076

Fax number: 56-2-342-1132

E-Mail: HIPERVÕNCULO mailto:Isuàrez@interactiva.cl lsuàrez@interactiva.cl

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