“She rubbed another match on the wall. It burst into a flame, and where its light fell upon the wall it became as transparent as a veil, and she could see into the room. The table was covered with a snowy white table-cloth, on which stood a splendid dinner service, and a steaming roast goose, stuffed with apples and dried plums. And what was still more wonderful, the goose jumped down from the dish and waddled across the floor, with a knife and fork in its breast, to the little girl. Then the match went out, and there remained nothing but the thick, damp, cold wall before her”.

“The Little Match-Seller” by H.C.Andersen, translated by H.P.Paull (1872)

“The theme with variations is a very well-known musical form. As a rule it starts with the execution of a theme, followed by a number of variations, and concludes with the execution of the same theme once again. An ingenuous listener could take this progression to be a cyclical structure, but that is not so. What is so fascinating about this form is, that it only seems to give the impression of returning to the beginning” (Introduction to the discussion on “Minima Temporalia” by G. Marramao 1991)

The arrival of a new member in a group always awakens a certain curiosity but also ambivalence, disorientation and anxiety. According to theoretical and clinical group experiences, one should expect that an uncanny effect will overcome the entire group field.

Normally, this is obvious to us in clinical practice, but in work with an anorexic and bulimic adolescent group, which we define as a mono-symptomatic group, and furthermore with the same gender and generational identity, there's a different aspect to consider. The uneasiness does not concern so much the patient who is new to the group, but rather the fact that she usually brings a cyclical and repetitive dimension to the group, that is already part of the group's experience. The new patient tends to transmit and propagate the repetition of the symptom in an area that is well known to her, and is amazed and disappointed when she finds transformations of the anorexic and bulimic ‘language' already thriving. The newcomer, through her symptom could trigger off, through primary, identification mechanisms with the more archaic zones belonging to the other patients in the group, the anorexic-bulimic element that the group's bond could have loosened up a bit, prior to her arrival.

I'm referring to the well-known repetition compulsion concept that is particularly intense in anorexia and bulimia, but becomes oxymoronic when faced with an adolescent phase with irreversible modifications of the body and relational configurations; what's worse, is when the oxymoron disappears and consequently, an annulment of the corporeity and sexuality comes about. This corresponds to the collapse of any type of object relationship, thus resulting in a destructive narcissistic dimension under the aegis of a “repetition loaded with unlimited, self-destructive potential”(Green, 2000 154).

In my experience alongside patients at risk, whether risking their lives as in anorexic patients, or risking psychotic breakdowns as in those suffering from bulimia, repetition is a common thread that runs through all these patients, “an apparent continuance of an immutable trait that nevertheless can conceal almost imperceptible microscopic changes” (ibid.).

If the repetition compulsion is a central issue to psychoanalysis, in the experience of this group, we are talking about a series of concatenations repeated in the same rhythm, the same tone, and with variations. There's a cohesive and chaotic participation to repetition that goes far beyond primary and archaic identifications.

In the group the symptom is exhibited openly and communicated by all the members: the group always repeats the same way of presenting itself and its visibility. In this group, not only is it extremely difficult to raise up memories and representations that are very precious when they emerge from the unconscious, but the group even has difficulty in tolerating behaviour and ‘acting-out' that's not anorexic or bulimic.

We must keep in mind, that in an individual analysis “the patient repeats instead of remembering, but you could also say the patient repeats so as not to remember. The more he repeats the less is remembered, and the less is remembered, the less he remembers why he is repeating, in the end an idea of his story is lost” (ibid.); the repetition feeds itself and in order to avoid mortifying monotony, sometimes it reaches such a level of excitation that even life is at risk. In the group, these repetitions transform themselves into excitative contagions of eating ‘acting out', repeated in a dimension of “sterility because of the eternal starting all over again” that is triggered off every time a newcomer is introduced into an identity dimension which cannot be transformed. How can we dissolve these bonds that are so sterile, stagnant and mortifying, “as if they belonged to atemporality? …in which little or no capacity of transformation and defensive rigidity prevail”? (Green 153). We turn to Green for an answer: “it seems that the solution, where possible, but often it is not, can come about through trying to dissolve certain closely interwoven internal bonds that are responsible for this obstinate immobility, without expecting however, that this alone will produce the desired result. However this is the preliminary phase, and will be responsible for what follows” (Green 54), in other words, it could be a way to “free the subject from the atemporality of a perpetual repetition” (Faimberg 198).

During adolescence this issue is a fundamental point of reflection: the adolescent phase is subjected to a physiologically irreversible period ‘ per antonomasia ', that produces necessary uncertainties and unsaturated questions on the self and on relations. In the case of anorexic and bulimic symptomatology there's a reversible time, that “under the aegis of a circular causality, can only take refuge in something foreseeable and more determined” (Abraham G. De Senarclens, 1999) thus becoming an end in itself, stagnant and lifeless, lacking development.

Why is it then that we embark upon treatment of the group, when the repetition compulsion in individual treatments is already so complex?

K.Abraham comes to mind when he wrote: “the psychoanalyst has to face the problem of why the patient who wants to die, chooses the long and uncertain way by starvation” (1916).

“PRE-TEXT”

Psychoanalytic theory on groups, but above all clinical theory, still had to be conceived when Abraham wrote those words, and we will never know whether he would have approved of group treatment for those who have chosen to die by starvation.

Now that we have this tool it should be employed by those who have the competence, if it has significance, as an ethical challenge towards life with respect to death, and also with respect to a needful revitalization of the libidinal impulses compared to mortifying crystallization that doesn't necessarily lead to death, but ‘encysts' in an emaciated survival.

In the adolescent group made up of anorexic and bulimic patients, when a newcomer enters, a “pre-text” comes about for creating shared and surprising symptomatic mirroring in which the state of isolation and the relational void, seems to loosen up a bit. What is common to these patients is that they are really alone without an object, or they perceive the object to be extremely lacking. They usually accept a relationship with another intended not as an object, but as a mirror. “At last I've found someone like me” is a phrase often heard in this type of group. There's someone “like me” but not someone “with me”. These patients can accept “someone like me” and it will be the therapist's task to bring about the gradual transition to accepting “someone with me”.

However, in a mono-symptomatic group, the specular dimension, in one way or another blocks an almost uncontained explosion of intertwining projective identifications thus avoiding a suffocating atmosphere congested with split, pathogenic and envious elements that would lead to “evacuations”, (Ferro 2002) and fragmentations in the group field.

In the case of shared mirroring, it will be up to the therapist to observe the diffractive elements during the course of time, thus bringing the underlying figurations of the subjectivity and the fragile identities to the patients' attention.

The mono-symptomatic group is the “pre-text” to a possible cure, because expression of new tolerable ties can start with objects similar to the self, in other words, the part of the self that is behind the symptom – thanks to a strategic direction on behalf of the therapist. The therapist follows the course of diffractions and ‘possibility of breakage' in the realm of mirrors with extreme delicacy. The therapist has to reach the labyrinth of the intra-psychic and the asymmetrical inter-psychic (the place and the time of the generations, and of the other, and not only what is similar to the Self) in order that the group can gain therapeutic and transformative benefit, and not only be linked to a monotonous solidarity.

FROM THE PRE-TEXT TO THE TEXT

Green reminds us that a symptom or an illness that expresses repetition “cannot be seen merely as an occult memory of a past illness, but it is a real enemy, alive in the present”.

In this realm of mirrors, breakages and diffractions are unveiled, but the therapist does not participate to this mirroring game. In an adolescent group of anorexic and bulimic women, generational differences, corporeal differences and gender differences with the therapist, are particularly noticeable, especially if he is a male. Indeed the group, in the way it adheres to itself, can negate, hallucinate, attack or exist in an illusory dimension of being cared for, and imagining that the therapist merges with it; here the therapist not only has the task of working on these mechanisms, but above all must not succumb to the repetition that's at the base of them.

Repetition “cannot be seen merely as an occult memory of a past illness, but it is a real enemy, alive in the present” (Green 2000). Repetition is manifested in the present, and in the present session; gradually, the therapist ventures into the automatism of the repetition, and armed with unlimited patience, finds faint traces (Corrao,1998) of its origins inscribed in the somatic; repetition as Green reminds us, is an enemy of life, so we need to ‘domesticate' it, in the sense of identifying ourselves with it, understanding its very roots and using intuition to understand the other, in order to get it to loosen its grip.

If we educate ourselves to listen to repetition in the group, we can appreciate its variations.

What else can we perceive behind diets, stuffing food in, vomiting, laxatives, scales, weight lost and regained, and gymnasiums?

During the past years, I've noticed that a sort of counter-transference prejudice has been taking me over, that manifests itself when new patients enter the group, and I am ready to hear, about diets, calories, vomiting, unattainable cravings for food, and foods classified with obsessive precision. Unfortunately, having these aspects already in mind, the curiosity that every analyst should feel when faced with a new patient diminishes. The repetition of the discourse could cause a preconceived way of listening that has nothing to do with an encounter between different voices that can lead to a creative giving voice to everyone; but above all there is the risk of losing the capacity of listening to the variations.

TEXT

Giulia, a patient at her second session, that had presented a long list of food she could not eat, says to Teresa, “If you are able to eat Parmesan cheese, what are you doing here?” And Teresa, a patient with two years in the group answers, “ I eat everything, but the problem is, the thought of food is always on my mind”.

“This is what my mother cannot understand”, answers Simona, with several years in the group, “I eat everything now, and she thinks I'm better, but I'm not, I still feel insecure and I always have this thought in my head”.

A remonstrative phenomenon takes over the group, all the patients complain about how much suffering the illness causes, and how their parents are often deceived by the disappearance of the symptoms.

Simona's discourse introduces a new scenario: the mother-daughter relationship.

I remember nine years ago, when I first started, how happy I was when a patient was able to construct a first meaningful link between the food problem and the relationship with the parental figures.

Simona's problem, similar to the stories of all our patients, gradually became an issue that involved the whole group, thus enabling them to feel united and to reflect themselves in it. Intrusive and absent mothers, absent, violent and sometimes incestuous fathers, were introduced by the patients to the group scene, thus enabling reciprocal and specular insight through an identification process.

Were they identifications, or just imitative mechanisms for creating a ritual of belonging?

‘We are anorexic and bulimic because we are deprived of our parents, or our parents were too intrusive', is the main drift of their interventions. I believe that this is important material for reflection; exactly how much are the parental figures introduced into the group fruit of authentic pathos? Or is it a group contagion indicating necessity of belonging, nonetheless legitimate, but not corresponding nevertheless to all of the patients' emotive and affective family vicissitudes? This brings us to deduce that in a group, and in particular an adolescent group, we can observe another phenomenon of repetitiveness: “the parents are also involved with the illness”.

Tiziana, at her third year of being in the group, adds, “our parents certainly count a bit, but the truth is, we have to look inside ourselves to see what shambles we have created”. Anna, the other newcomer to the group, astounded me by saying, “its not the solving of the symptom that counts, but that the problems inside of us are really faced”.

Are we looking at a superior insight, or an automatic response to Tiziana? Has Anna come into contact with her internal reality or just furthering a problematic repetition that doesn't concern so much the symptom but what is behind it? All this can certainly seduce the analyst who is working on these issues.

In order to reach the discourse on internal reality, it's necessary to pass from the repetitiveness of the symptom, to the repetitiveness of the relational parent-children configurations.

It's as if a sort of spiral from a diachronic point of view has insinuated into the group stratification, where gradual fertilization of the arid ground (anorexia) facilitates growth of plants that have been sown there over the years.

The problem is, are they real plants that after ten years have found a suitable environment and are finally able to grow? Or is it growth of clones that only appear to think?

At this point, perhaps it's worth mentioning Giulia's intervention following Anna.

“I don't understand anything that's going on inside of me. I feel really uneasy and at the same time I want to be able to sit down and eat a big dinner, but I know I would never be able to do that. Do you all know the story of the little match-seller? I feel like the hungry child, out in the cold who watches people eating, through the glass pane of a window. I'm the one who puts that glass pane in front of me! Who ever said we wanted to be anorexic? I am envious of those people eating”.

Teresa cuts in, “That reminds me of what happened to me the other day. While I was thinking about the usual, boring eating problems, I went on to the balcony to smoke a cigarette. I noticed a person, probably a tramp, huddled on a bench in the street opposite my building. The sight of that man shocked me, I staggered back and my head spun round, perhaps it was the contrast between him and my comfortable home, that impressed me so much”.

In this sequence of interventions, it's possible to detect instant emotive contents, that are giving rise to a more meaningful order compared to the previous interventions; I felt it was a real breakthrough the fact that something had come from the deeper levels and was expressed in the hic et nunc of the session.

These sudden intuitions of Giulia and Teresa, are the gateway to development; development is “ a succession of phenomena that appear unconnected, but after a particular intuition assume significance and coherence” (Corrao 83 vol. 1). The function of the analyst at this point is to “bring to the fore those elements that otherwise would remain invisible” (Videlman), in the sense of drawing together and making known all that emotive strength and energy that is capable of interrupting the repetitiveness.

The little match-seller, a story read in childhood, is painfully resigned to light one match after the other deceiving herself she would get warm, in a world that will never include her, because it ignores her plight.

At the beginning Giulia is identified with the little match-seller's world, but after having launched the ‘bomb' of her envy, she breaks away from that situation in the group, a particularly virulent state is created that is difficult to tolerate: Teresa cannot accept the idea of envy, neither envying nor being envied, and she has to immediately turn her eyes away from the tramp alone on the bench; what's more, she is terrified to see the deformed reflection of the other, so similar, but much worse off, wrapped in his hunger.

The old concept of envy, fallen into disuse and even sometimes banished in vast areas of non-Kleinian psychoanalysis, reappears with authentic arrogance in the above-mentioned patient.

Giulia doesn't eat in order to repetitively remain in a condition of primary envy, and Teresa, supported by a false tranquillity cannot let the starving tramp into her mind.

What interpretation can we give at this point? Perhaps we can give a transference-interpretation of the group, describing it as capable of containing the little match-sellers that feel a sort of unnameable terror when they are faced with other starving people? Or else, paradoxically, try and explore with a different interpretation past theoretical roots, in which alongside the fear of wanting to die of starvation, some members, because of their envy, could consent to transform the little match-sellers in detonators to blow up the restaurant?

After all this, the therapist's fragmentary, lacerated and sanguinary thoughts could lead him to doubt the certainty of his theories and not respond to the compulsion of the patients by repeating models that can be renewed thanks to the extensiveness of psychoanalytic thought and are well-presented, but have very little to do with the patients' emotive resonance.

How can one establish contact with a group of patients through an intervention that is the outcome of a counter-transference bond, and at the same time the result of a group of theories stratified in the therapist's mind?

The interpretation of an envious attack (the match that lights the bomb) would be experienced by the group as another bomb and would probably cause an explosion. Regarding this, Winnicott comes to my mind when he writes about destruction: [the interpretation] “is not necessary for the child's impulse to destroy, but for the risk that the object does not survive” (Winnicott 162). In my opinion, to have the destructive phantasy of the patient in one's own mind is necessary, whilst it would be illusory and omnipotent to give an interpretation that assures the survival of the group container from an explosion; I believe the sum of these thoughts can lead us to say that “this little match-seller, starving and out in the cold, would have wanted to light up the fire-place in the restaurant with her matches, if only someone would have noticed her” giving the little match-seller the idea of having a small tool in her hand.

On concluding, I consider these past years of working with anorexic and bulimic groups, above all, has allowed me to be in contact with the repetitions among patients, and also has allowed me to re-examine many clinical and theoretical processes; depending on whether I have utilized them in an integral form or mixed them in a confused manner, has permitted me to get away from rigid chains, enabling me to get closer to the enigmatic world of anorexia and bulimia, that is almost impossible to classify into any defined schema.

I have a confession to make to the reader, ten years ago when I embarked on this group, the dogma of the Bion container that is capable of containing the majority of projective identifications of the patients and return them decontaminated, reigned in my mind. I needed to totally rely on an important theoretical base, that Bion certainly intended as being one of the more possible ways of procedure.

The creativity of a theoretical model of such importance could have become for me the repetition of a theory that in time would have become a fetish. In such a situation, I would never have been able to get close to a mind or a body “with which one has to co-habit….in which there's nothing…a hole… a void” (Terninck), and even more, to approach the mysterious, female world.

Translator's note: diffrazioni ed effrazioni , a pun in the original text.