Key words: Group, Photolangage ® , Institutional crisis, Initial fantasies.

Introduction and assumption

This paper describes the application of the Photolangage ® mediation during a training intervention at a healthcare institution going through a crisis.

We were approached by the establishment management, wishing that an action be undertaken to assist the nursing teams. This action underlain two requirements: on the one hand, we were invited to present mediation, on the other hand we were requested to help the staff to take the ownership of it. The objective being that this mediation be usable within the framework of working groups. These requirements lead us to propose an action using the Photolangage ® . After the preliminary contacts we promptly come to a working hypothesis which makes us postulate that this site is going through an institutional crisis. This crisis is lived as both an ongoing suffering of the staff and the urgency to intervene.

Based on the work of differed action, our findings allow us to uphold the hypothesis that the use of photolangage ® , applied at this time of the institutional history, allowed the emergence of the initial fantasy 2 around the establishment foundation. This emergence was set up at two levels: with the account illustrated by photographs (used during the Photolangage ® meetings, which is the specificity of the method) and the verbal exchanges.

We will start by presenting the establishment, its request - obvious as much as latent - and the analysis that we did of it.

We will then develop the answer that we supported with the proposed training work, the implementation of the Photolangage ® exercise and the hypothesis related to any work of differed action. Our methodology does not include a detailed account of the meetings but rather a selection of both the exchange main points, and the photograph show.

We assume that the system elements and the instructions specific to the Photolangage ® mediation ³ are known to the reader. For the sake of privacy, names of people and places have been kept fictitious throughout this presentation.

Introduction of the Institution

«  Up there on the mountain, there was an old chalet, white walls, roof of shingles... » ( Extracted from an old French popular song. )

The main purpose of this Institution is the handling of patients suffering serious chronic pulmonary pathologies resulting in limitations in their daily life. These pathologies have multiple etiologies: one of them being the nicotinic dependence. Some patients suffer multi-dependence: alcohol, tobacco and medicines addiction. According to the nosology in force, the Institution does not accept hard drug addicts. The majority of patients went through many other health or therapy centres. As a nurse put it: " Here, it is a place of the last hope ". Geographically, the Institution is located on an isolated site, far from large urban centres.

The ideology of the establishment posts an univocal reference to group dynamics. The group, with the interactions that it causes, is invested in a role of precursor and backup of the processes of change sought for the patients. The later are hospitalised for a period of one to several weeks. They are taken into care throughout the day, according to different areas of activities and approach:

- Physically: rehabilitation in swimming pool, respiratory kinesitherapy, walking.

- Medico-somatic: dietetics, "therapeutic lesson"

- Psychological: talking group.

3 Reference to the book: "Photograph, Groups and Psychic care", C. Vacheret and al.

The request

The institution management, which we will name "the Mountain", asks us to intervene with the multidisciplinary working teams to work on group dynamics. This action is first intended for the teams animating the "therapeutic teaching" groups, in order to help them in their practice. These groups function with two staff members. One plays the role of a coordinator, the other one acts as the expert. They can be alternatively coordinator or expert.

The expert gives therapeutic teaching, that is the technical and theoretical speech supposed to generate modifications of representations among patients with respect to the disease, especially for nicotinic weaning.

The coordinator manages the exchanges and controls the group dynamics.

In the very formulation of the request, we are told that the nursing staff is struggling with group phenomenon which mitigates the effectiveness expected from this handling method.

We learn that this systematic group approach was established recently and that, simultaneously, the institution moved into brand-new buildings.

" Some staff are suffering, some patients get breathless but all work in group. "

Our analysis

During our first analysis of the request we detected three characteristic elements of the challenge at stake in this training action:

The notion of emergency :

This one is spread over several levels.

•  By the frequency of the contacts between the applicants / decision makers and ourselves,

•  By the pressure that sets up straightaway and requires that we bring immediate answers.

•  By the description of the team's strong unrest.

" Some staff suffer even though they work in group. "

A bad internal organisation generating confusion :

From the beginning, we are struck to note that the people to whom we address our telephone messages are never the same ones who answer to us. We feel dragged into a hide-and-seek game which takes place on a chase race pace, because the one we speak to is never the one who answers.

Therefore we relate this confusion and this feeling of emergency to the question of undifferenciation.

The indifferenciation of roles and functions :

This lack of differentiation also prevails in the administrative sector: thus, it is a (psychologist) nurse who first contacts us. Thereafter we understand that she does not usually intervene in this capacity. She has recently been managing an institute in legal relation with the healthcare institution where we must intervene. Finally the administrative director interferes in the contacts by answering calls that are not addressed to her, so that we are unable to determine how the collaboration is actually organized.

The indifferenciation that operates at the administrative level is relayed to the nursing practices of the "therapeutic teaching" groups at the level of both the expert and coordinator roles. Indeed, when we wish to understand how the elements of the system are organized and what is the role of each nursing staff member in the therapeutic group (pointed as "suffering" by the institution) the explanations refer more to the goodwill of each one than to any sort of legitimacy. These roles are not justified by reference either to knowledge acquired and recognized in the institutional history, or to a diploma.

Our response

Taking these first analysis elements into account, we offer to work in groups using the Photolangage ® specific mediation. It seems essential to us that the nursing teams do experiment - within a clear and differentiated framework - the stakes of a subjective position. One of the Photolangage ® instructions initiates it: "we all are invited to say what we see as similar or as different on this photograph."

Here is a subject/group gap and a difference between each member of the group with, as a corollary, the creation of a playing place. Differentiation is the core of this work in-group with mediation.

In addition, while keeping our roles as trainers and coordinators, we take part in the meetings like the nursing staff to whom they are proposed. Being ourselves participants, we consider this position as not dangerous regarding narcissism.

Within the framework of the training, we propose that the experimentation of the group dynamics be subjected to analysis. Indeed, the training is not only a group experience. The work of analysis that follows each meeting generates an elaboration process inherent to any work of differed action.

Progression of the intervention

Several meetings of Photolangage ® will take place during the training, being understood that the last meeting has the particular statute of an evaluation meeting. Its contents will not be included in this paper.

At the first meeting a question is asked: what does "communicate" mean to us? With the support of a photograph, we speak about it with the group. The group realizes that several participants have chosen the same photograph. The sharing of the mediation object is done around three photographs, each one representing a group. First picture: a black woman and a white woman sitting back to back, the black woman carrying a baby, the three of them exchanging glances. Second picture: a group of young people sitting and discussing in the countryside. Third picture: scene of a group in an African village surrounding a spokeswoman. These photographs are the first three ones presented during the meeting. In addition, a participant - in contradiction with the announced instructions - does not choose a photograph. Then, another photograph (two men talking, one very small carries a rifle on the shoulder, facing a tall man) generates also many contrasted and sharp exchanges of view, having "the difference" as a central topic: how is it experienced? What does it come from? This photograph is presented right in the middle of the meeting; afterwards it will appear as the central elaborating key. Finally, one of the participants cannot speak about his photograph. He is prey to a significant movement of sadness. His neighbour can name this emotion and refer it to the selected photograph (a father and a child are face to face). He speaks in his own name about this emotion that himself could feel. Then the group goes through a moment of intimacy.

During the analysis session, the participants quickly realize that the differentiation issues are already exerted around the very material aspect of the mediation object: when several people choose a photograph, how is the exchange done? How one moves through the area to select a picture? How does one feel when divested of a picture in order to allow that other people can present it too? Is this even possible? Then the action of non-selecting a photograph is seen as a moment where the individual position contravenes the framework tacitly accepted by all 4 . The associative work then brings back to the untimely departure of certain patients from the "therapeutic teaching" group.

Other staff members explain that, in their groups, some patients recall multiple traumas of their own life. Consequently they feel overwhelmed with emotion and leave the room.

Some staff members point out that, in their groups, the expert position is more comfortable because he does not need to manage this emotion. The coordinator has to do it so that, in most of the cases, he has to walk out behind the upset patient and talk with him about it. This moment is not "containable" by the group.

There too, the exchanges of view are many and sharp. Then the participants establish the link with the emotional reaction which took place at the time of the Photolangage ® meeting. At this moment the group could contain the emotion felt. Thanks to the mutual support, the group passed from the emotion felt to the named and shareable feeling.

The elaborative work of reflexion about the differentiation is part of both the experiment of the Photolangage ® meeting and the differed analysis meeting. But above all, having taken ownership of the rules of the game of this space, the group spontaneously requestions its own institutional practice.

We will understand that the group, feeling sufficiently solid, will continue its work of thinking and will confront itself with the question of the institution founder.

"Up there, on the mountain is now a new chalet..."

4 BLEGER J : "Psychoanalysis psychoanalytical framework"

Next Photolangage ® meeting (question asked: You choose two photographs, one recalling the experiment of a group's pleasant moment, the other recalling a group's difficult moment. As organizers, we do not attend this meeting.

It is significant to note that this meeting takes place on the following day. Everyone went back to his (her) private life in the evening and overnight. Now they come back to sit again in the training group.

Moreover, we have modified the structuring of the question and also the elements of the device by not attending the meeting for didactic reasons. Will the group members notice these modifications? How will they take them? How will they analyse them?

When the first photograph is put forward (several horses and their riders walking away on the horizon), the group notices that a member has selected it to speak about a difficult moment and that another member, quite to the contrary, evokes a pleasant moment based on the same choice. The pleasure of the ride is then developed: "to go elsewhere", the pleasure of being carried by a solid animal that we master, the pleasure of sharing with others the same relaxation time... but also the anxiety to face the unknown, the difficulty there is to fully trust an animal which can turn out to be untameable (one thinks here about the metaphor used by Freud to characterize the unconscious and the ego).

Here again, the exchanges are numerous and take time.

Then much harder photographs are presented: a photograph of armed warriors, a photograph of a rubbish dump, a photograph of a group including a girl obviously sad and becoming withdrawn into herself and finally a photograph picturing a statue with a human face, hung by ropes under the armpits. What is then happening?

We postulate that the group will enter upon the question of the institution's origins. A majority of recently appointed staff members seem unaware of the institutional history. Some other old-timers would be holding the secret of the origins. However the latest are those who speak less. They do not disclose the secret. Let us also point out that the old buildings were recently left in order to move into a new building, functional but without history.

Based on (1) these contextual elements, (2) the selected photographs, and (3) what is experienced and said during the meeting, we propose a reading of the myth: A doctor, good father, has set up in this isolated place. He took in sick children, keeping them away from the polluted city (photo of the horse-riders).

The continuation of the story covers the betrayal made to this founding father. The children of the founding father chased him away or killed him (photo of the armed men) to take his place and change everything (methods of care, buildings). But then, suffering and loneliness come (photograph of the dump, photograph of a group with the sad and isolated girl). All is done in-group and it is precisely the question of the group that causes suffering.

By the end of the Photolangage ® meeting, the photograph of this statue, hanging on ropes, is presented. The impression coming out of it is very strong, with this human face and glance, fixed in a hanging position, with its earth-coated surface scratched, as broken up: it looks like a true ghost, half-man, half-object. At this time the group feels a great emotion. This emotion is shared; the words come, transferring onto another scene what the photograph actually represents. The participants evoke how "the group can carry something heavy".

By sharing the emotion triggered by the evocation of the father during the former meeting, the group could start working out the institutional archaic pictures, supported by the group's imagination.

The suffering of the teams is no longer blocked. It is no longer inaccessible and is discharged from its dangerousness.

One can note that the participant who formerly felt uneasy, can now quietly present his photograph. He even reassures the group by explaining, smiling, that sadness is not a permanent state...

Thus one can notice how the group, because of the institutional crisis currently experienced, takes over the Photolangage ® to question its own functioning.

But above all, the specificity of this mediation, by using the visual mode, gives rise by affinity to the mobilization of the archaism and the fantasies that become intermingled in the mode. That is to say: the foundation, the birth of the institution, its transformation and its growth.

By putting under stress both the visual element (the photograph) and the discursive one (expressing in words) leads to a group specific space where the imagination and the pre-awareness, can be displayed as a linking point between the conscious and unconscious processes.

Conclusion

Thanks to this re-elaboration work of the institutional archaic pictures, the group could free itself from the crisis and the accompanying ideological speech. Recovering the pleasure of the psychical game - like a child enjoys rebuilding his pyramid of cubes - the group has recovered a space of thought and elaboration. It has found again certain stillness.

A few months after our intervention, the institution gets in touch again with us. This time, it is done in a serene way and by the suitable person (end of the chase race game). We learn that the training, in some way, boosted the work dynamics. The teams could return to their groups and get involved in a thorough training on the "therapeutic education". They use this tool and this mediation taking into account the specificity of the inpatients.

Thierry DUMONT

Genevieve SABATIER

Lyon, May 2001

References of the articles and works quoted :

•  BLEGER J "Psychoanalysis psychoanalytical framework" in Crisis, Rupture and Surpassing , KAES R. and Al, Dunod, Paris, 1979

•  KAES R. et al. Suffering and psychopathology of the institutional bonds . Dunod, Paris 1996

.