Introduction

We are working as clinical psychologists in a long term care institution with physically and psychically dependent older patients, some of whom suffering from of Alzheimer or other types of dementia. For some of them, we have set up a therapeutical service to remobilize psychical functioning, in order to stimulate their creative potential and their capacity to experience pleasure. Indeed, these residents have to cope with multiple losses due to ageing, including the ultimate loss, that of their life. Among these losses, the loss of their dwelling, and sometimes that of their husband or wife, and its corollary, the adaptation to the institution, often causes great suffering, at both personal and familial levels. With Photolangage ã , we propose a therapeutical framework susceptible to bring help and support, in order to let them work through and assimilate this stage of their life.

Definition of the technique

Photolangage ã is a method developed by psychologists and psychosociologists from Lyon ( France ) , using photography as a mediator of thought, speech, and expression in a group. Its theoretical framework within the field of psychoanalysis has been elaborated by C. Vacheret (1984), based on her practice in psychiatric institutions. These days, Photolangage ã is used as a therapy with adolescents, adults and elderly persons, but also as a method for dealing with situations of crisis in institutions, or firms, in the domain of training, or also for fostering the emergence, assessment and evaluation of a demand in a group. The pictures presented here are from professional photographers, and are grouped by themes.

Working hypothesis

Our hypothesis is that this group technique, with photographic picture as mediator, allows to remobilize the psyche of eldering persons. Actually, with advancing age, psychical energy weakens, with desinvestment and impoverishment of primary and secondary processes as consequences. Thus, picture touches the affective, the sensory, i.e. the " Range of the Originary" (" Registre de l'Originaire ", P. Aulagnier, 1975), a level that is anterior to the primary and the secondary, the range of bodily experience and psychical inscription. The originary is the support of preconscious representations, the basic canvas from which access to representation becomes possible. It is through to bodily experiences of pleasure that the psyche becomes. The bodily experiences of pain bring, on the other hand, a hole, a blank, in the psychical web. We find here again, as S. Freud said (1920) the primacy of the pleasure principle, and from there the notion of a " good enough environment-mother " of D.-W. Winnicott (1969) in the primary relationship with the baby. The thinking of the demented person, at the extreme point of destructuring processes (primary and secondary processes), gets repleted of representative holes. If dementia can be defined as " a psychiatric disease characterised by a progressive and irreversible intellectual weakening " (G. Abraham and I. Siméon (1984), we approach it from the perspective of psychical deconstruction. The originary, background of our psychism, can by mobilised by means of image. Affect can be untied from representation, but not from image; the group allows, by its dynamic, to " plug in progressively the associative processes " (R. Kaës, 2000) and the intersubjective exchange allows to tease up the intrasubjective, and to facilitate access to thought, word, and representation. Links are rewoven and revitalised thanks to the activity of the preconscious.

The process of aging

We approach old age as a stage in the development of the person, a phase of life with many losses : narcissistic (body image), loss of relatives, anxiety regarding approaching death. These actual losses reactivate previous losses, in particular the mourning of the first separation from the mother, as well as the preceding conflicts, this leading to a psychical disorganisation and destructuration. It is assumed that the psychical organiser of this senescence crisis is death, as proposed by J. Gaucher. According to this author, the psychical reorganisation of the older person would proceed through a " reversion of the ego ideal onto the past ", by a work of life review, a return to life turning points, in order to relive emotions, pleasurable experiences, but also to give meaning to traumatic events and conflicts. Successful aging would be a growing old with acceptance of death, considering it without anguish. Life review would be a sublimation, a creation, according to M. Péruchon's proposal (1994). Aging is a psychical work to be accomplished by each and everyone, it is a process. In agreement with J. Bergeret (1974) who considered pathology in continuity with normalcy, we consider dementia in continuity with the process of aging, bringing to its paroxysm the progressive psychical deconstruction. The demented person would be, according to Maisondieu (1989) in a state of death denial, his/her psyche being emptied of its representative, deconstructed in order not to think. There is a progressive return to the " sensory-perceptual pole " (Range of the Originary).

The organisation of Photolangage ã

We receive five to seven residents for each group, directed by two leaders: a clinical psychologist, and a member of the care taking team who will be the referent of the group. We think it is important that one member makes a link with the team, in order to avoid a split between the thinking space and the caring space. Furthermore, the care taker is the bearer of the present reality of the patient. She/He is, in some way, her/his " auxiliary ego ".

Indications

Candidates are usually proposed by the nursing team at institutional briefings. We try to balance the groups in order to have enough homogeneity among the participants concerning capacity for expression abilities, but the psychical pathologies may be different (dementia, psychosis, depressive disorders...). The group meets at fixed days, a fixed place, at fixed regular times (once a week), for a limited duration (from three quarters to one hour according to the groups). These are closed groups, in which the patients commit to come regularly for a limited time (usually one year). The fixity and permanence of the organisation are essential elements, sometimes difficult to maintain in an institution. However, this permanence is the guarantee of trust and safety, which are necessary for the containment of archaical psychical movements, of pulsions, in order to let the group be the place of deposit and of psychical elaboration, to let it structurate itself, and that symbolisation may happen.

The sessions : There are two phases

- Firstly, the choice of pictures, starting with the question proposed by the leader : " Choose one or two pictures that evocate for you... ". Then everyone is invited to let himself being called out by one or two between those we propose (between 20 and 30). The rule is given to make the choice in silence, in order not to influence each other ; the photo is first chosen by eyeglance, so that everybody may dispose of all pictures. Only when the choice is completed by the group, is everybody allowed to take his/her picture. If a photo has been chosen by several persons, they shall express themselves at their time about their choice, even though they do not have the picture directly in hand.

- The second part of the session is dedicated to group exchange around the photos : each one is invited to present his/her picture when s/he wants. We ask the group members to listen with attention to the person expressing him - or herself, and then we invite everyone to say what s/he does see that is similar or different on that picture.

The role of the clinical psychologist : S/he warrants the respect of the framework, the quality of listening, so that this space be a place of game, of shared pleasure. She reformulates, makes the round, creates a climate of trust and security. We decided to choose pictures also ourselves, as the patients do, to implicate ourselves. This way, the patients can identify themselves to us, lean on us, we become " psychical prostheses ". This is particularly important during the starting phase of the group, because the patient always lives it with anxiety : " What shall you ask us to do... you know, I have only may basic school certificate... I remember nothing ". The two leaders choose the themes together, as the sessions follow each other, which requires a consultation between them before and after each session. This work on the intertransfert afterwards is essential, because it allows group elaboration, and positions the care taker as a listener, just as the clinical psychologist. He is then a cotherapist.

The group work : As C. Vacheret (2000) indicates, one of the essential qualities of the group lies in its ability to regulate pulsional drives, life and death drives, which get expressed through imaginary productions. The modalities of expression are diverse, verbal, gestual. Everyone speaks of her/himself, with his/her imaginary, her/his story, his/her mournings, his/her traumas, her/his joys, her/his psychical troubles... Everyone is touched by the other ; " images cross each other, strengthen each other, cumulate to the point of comforting the subject in his/her perception, or to shift him/her off his/her initial vision ". Photolangage ã proposes a space for thought. As the sessions follow each other, as the game of identifications and associative processes progresses, intersubjective ties are woven and the group structurates itself. The group in the sense of R. Kaës (1976) is that intersubjective complex which has its own psychical reality (group psychical apparatus), under the effect of the inconscious of the subjects composing it. The group psychical apparatus allows to articulate the intrasubjective with the intersubjective relationships. It is an apparatus for linkage, for transmission and elaboration. Let us now consider a clinical example.

The case of Mélanie

Some elements of her story : Mélanie, presently 80 years old, is the second, unwanted, child. At her birth, her elderly sister is twenty years old, and her mother forty. Her maternal grandmother dies when she is one year old. It was said in her older sister's family that she was not normal (intellectually deficient) because of convulsions she presumably had during her childhood. Mélanie was not raised by her parents, but by a cousin of her mother. Her older sister died from tuberculosis at the age of twenty six years. Mélanie will say that she has been kept away from her because of contamination. When she recalls the death of her sister, she always says :  " It isn't clear, I don't know well ". She is than taken back by her family, and she tells us : " I have been raised alone by parents who could have been my grandparents, I have been spoiled, it wasn't funny, my mother was always depressed, I often had bronchitis and asthma crises ". She marries the widower of her first cousin " I took her husband " she often repeats. She brings two children to the world, one boy and one girl, she says of her pregnancies that it was great. She will place her children because her health doesn't allow her then to take care of them. Her daughter marries a friend of her parents, with whom she has two children. One commits suicide as a teenager, the other is married and has two little boys. Mélanie says that she never spoke to her daughter about her grandson's suicide. Mélanie's husband dies shortly after taking up retirement (they were shopkeepers) in a town near their daughter's home. She cannot tell anything about what occurred since. About her husband's death, she can only whisper : " It was too brutal, it can't be said with words " The recent periods of her life remain very vague for her. She goes to live a short time in her daughter's home, after the death of her husband. Because she cannot cope with her mother's difficulties, and in agreement with her brother, the daughter applies for an admission in a long term care institution. Upon arrival in the service, Mélanie falls into a deep depression. Her constant complaints, her multiple demands are such that the team cannot cope and does not know how to answer them. Indeed, Mélanie experiences great psychical suffering, that she expresses in a hypochondriacal and completely affectless way. When we meet her, she has been in the unit for six months ; she doesn't leave her bed, lying the whole day in a near foetal posture, her face very pale and expressionless. A permanent groaning marks her lips "  Ah, if you could know how much I suffer, it burns me, it presses on my head, it suffocates me, they find nothing, why I suffer " The relationships between Mélanie and her daughter are very difficult ; during her visits, Mélanie says : " We are very different, if I leave, I will not disturb her any more, she is very generous, especially with the others. " Her son, who lives far away, comes occasionally, as well as his children and grandchildren. Her family's visits are offend followed by episodes of faecal and urinary incontinence.

Caretaking : Aware of her unwell condition, and at the demand of the caretaking team, Mélanie obtains individual talks with the clinical psychologist once a week, and participates in the Photolangage ã group. She is also received regularly with her family, the members of the caretaking team, and the clinical psychologist for family support interviews.

Mélanie and the Photolangage ã group : Mélanie'group was made up of six persons (four women, two men, among them one psychotic woman, and four other persons suffering from moderate memory difficulties). The group met for eighteen sessions with the same referent caretaking person. Mélanie took part in these sessions with reserve and restraint, but always in an adequate way. She had to be solicited to provoke her expression, but she progressively invested herself, making interventions and asking spontaneously questions to the other group members. The representation Mélanie had of the group was well expressed by her during the last session around the question : " What you lived in the group through the year " as she chose a picture of three faces of men, who were looking at each other and laughing : " They are happy, one of them is telling stories " This choice lets suppose that Mélanie had a positive and containing representation of the group, that she took pleasure with it.

But we shall discuss a picture that Mélanie chose at different sessions, following the questions : " Choose a picture evocating an aspect of yourself that you like... (being taken care of, ...a mother...being angry...being a grandmother...) ". She chose a picture representing a young woman holding a baby in her arms. The young woman and the baby are facing each other. The first time she presented this picture, Mélanie could no stop staring at it. She could not tell anything about it. The picture in her hands, she seemed to be fascinated. We asked ourselves the question concerning this attitude bordering on fascination. It evocates to us the condition of being in love, artistic contemplation, the pleasure of a music, exctasy in front of a landscape, all these unspeakable states. When you lack the words, and when time gets suspended. The picture, as we did say above, sets in motion sensations, emotions, affect, the originary range inside each of us... i.e. our corporal experiences, our inscription. This sideration initially shown by Mélanie in front of this picture questions us concerning what she lived in the primary relationship with her mother. Indeed, this picture shows the tie between mother and baby, and the fascination of their stare at each other. If affect can be untied from representation, we observe well here that it is not untied from the picture. C. Vacheret (2000) underlines the importance of the look as a sensorial element on which the infans bases its psychical development, and shows that way the specificity of visual mediation as compared with other ones in the group, like music, drawing, painting etc. This author proposes to consider the gaze as a " window on interior life " of the mother, as a mirror reflecting the child's own face. In this mirror, the infans feels invested or rejected by her, and this induces in him, depending on the case, experiences of pleasure or suffering. He sees him/herself in the gaze of the mother, but sees also himself being looked at by her. The visual would then be, according to C. Vacheret, " one of the constitutive parts of self-representation and therefore, it would take a very particular place in the representative function of the subject ", and shall be an essential structuring and organising element of the narcissistic foundations of the subject.

We think then that Mélanie has experienced a deficit in the primary relationship with her mother. Registered into her bodily sensations, this deficit could not be represented. It is only some sessions later that, taking the same photo again, she will be able to say something about it : " Tenderness, the mother who holds the baby close to her heart, this is everything for her, this is a beautiful picture, how to take one that way ". An other woman in the group referring to the same picture, spoke of her sons who made her life difficult. Mélanie would then jump up, retorting : " There are girls who are real tomboys, who have a bad character ". Some sessions later, taking this picture again, she shall say : " My daughter is vivacious, but really, she is kind " . Following these sessions, Mélanie shall evocate again her story, her placement to her cousin home when she was a child, and her experience of feeling abandoned. Abandoned by her mother during her early childhood, she feels now abandoned by her daughter in the institution. Like in many other families, inversion of generations is operating when the parents become dependent physically or psychically. For the person who again becomes dependent on the environment, and this is the case for the sick elderly person, the first life experiences, the feelings, the emotions to which the mother could have given a meaning, become primordial again, even though they were in the background for their entire life. Thanks to the " sound and language bath " of the group, as R. Kaës (1984) does conceptualise it, Mélanie's preconscious could be remobilized, starting from the originary range, this " sensory-perceptual pole ". That way, Mélanie's present fears of abandonment could be elaborated and understood as a so painful revival of the first abandonment.

Conclusion

We have chosen this clinical vignette concerning a member of the group because we were strongly impressed by the state of fascination Mélanie showed when choosing this picture. Finally we underline the importance of counter-transference (of the feelings we lived during the sessions) and of inter-transference (what is being lived between and with the therapists) ; indeed, it is through our capacity to receive the feelings of the patients, to accept what we experience, and to elaborate it, that we solicit, in a first time, the originary register of the patients, and that we help them, in a second time, to rebuild their own representation. The aim is a " reconstruction " of their history, to give a meaning to their life from the feelings of pleasure or pain in the here and now during the session. We tried to show how the gaze, and therefore the picture, were a structuring and organising medium to support the failing narcissistic foundations of elderly patients. The pleasure, experienced in the space of the group, remobilize the libido of the elderly patient and allows him to continue to be creative. Indeed, all the themes touched on during Photolangage ã sessions led the group members to work much around the family. Then, the group continued with the aim to establish, for each of its members, a genealogical tree in photographs. Mélanie, whose psychical state got better, was able to collect from her daughter, pictures of her parents and ancestors, found in a chest in the family house, and also more recent pictures of her offspring's (grandchildren, grand-grandchildren, as well as a picture of her grandson before his suicide). During an individual talk, she was able to evocate the meaning of the act of her grandson, as well as her sister's handicap, that was never talked about, and to erase her fear of having transmitted a taint. Mélanie's somatic claims disappeared, and she is now able to go to her daughter for the week-end.

Let us also notice that we receive in the institution families for support interviews with their institutionalised relatives, and with members of the nursing team. These " intricated " caretaking services (individual interviews, mediation groups, family interviews), linked with the nursing team, seem us relevant and necessary in order to stimulate the destructured psychical functioning of the elderly person. These care spaces stimulate also the creativity of the institution, and operate as transitional space, in the sense of D.-W. Winnicott (1971). To remain psychically alive, to continue experiencing pleasure, is what seems to us to be fundamental in order to accept continuing one's life in a place that should be really a place of living. We shall always remind us what S. Freud said : " You are old, you shall die, you are agonising, but the desire is there, the desire is indestructible, it is the real law "... ; and we shall also remember that in 1956, at an age of 89 years, the architect Frank Lloyd Wright, started building the Guggenheim Museum in New York ...

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C. Bélisle and A. Baptiste are those among the initiators of the method, those who coadministrate the collection Photolangage©.

Infans : that one who has no access to speaking, according to P. Aulagnier (1975).

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