We are going to develop our own reflections leaving from two perspectives: on one side we are going to pause over the evolution of group psychotherapy in a Mental Health Ward (ASL RM/B), and on the other, we are going to analyse some peculiar configurations patient-group in the light of the theoretical- clinical conception by H. Kohut about narcissism and the Self.

Meeting others: the valuation of the group between fear and hope

Group psychotherapy, after a long period of time when it represented an additional option just chosen by some therapists interested in this research, in the last years, entered to take part in the list of standard services, so integrating completely itself into the intervention of Mental Health Centres up to the point of becoming the most innovative therapeutic proposal, even if it isn't as present as the individual treatment. The progressive extension of the context of intervention had results both on the group itself, illuminating better some of its aspects, and on the way of considering individual pathology. Thus, the group has been articulated according to pathology, age, themes, problems and activities in order to widen it up to containing the whole range of psychiatric disorders (Guimon2001; Stone 1996). We will give short notes on the evolution that the notion of group has just had up to now regarded as a therapeutic device in the Mental Health Ward, postponing the reader for deeper reflections to further researches about this topic.

The sending, of some members to the group, on some colleagues' part, at the beginning contained a certain quantity of ambivalence; the prevailing sensation was to deprive the patient from the individual psychotherapeutic work, considering more useful to concentrate on his personal difficulties and analyse them deeply, and, at the same time , to expose him/her to a relationship with other individuals, which was considered a potential source of a further disturbance. This was to be added to the idea that the exposition, to mental contents of the group considered too disturbing, occurred for the patient beyond any possibility of control. The lack of any support to identity the fear of standardization or depersonalisation, in short, all that constituting what Anzieu (1976) defined as "a primary threatening for the individual" was attributed directly to the relationship with others. Tensions with other individuals were not regarded as a result of the influence of the group but were connected only to a datum due to good or bad relationships among individuals. Because of an epistemological resistance to consider the group dimension (Anzieu and Martin 1986); therefore, in accordance with this point of view interindividual conflicts were not susceptible to evolution for the constitution of a stable and cohesive group structure which has therapeutic effects on its own members. In short, one could say that "the need of work imposed by the intersubjective condition of mind"(Kaës 1999) was considered by the senders an excessive burden for the patient who was to be inserted into a group. This being the case, the indication of the group on the colleagues' parts was given only when indications were not visible for a psychotherapeutic individual work or when we found ourselves in relation to situations of great isolation , because of this the group was seen as a social situation the patient was to be exposed to in a protective way to get some benefit. In a first stage, even if the therapist of the group wanted to differentiate himself/herself from these personal experiences, bu was partly influenced because of his/her individual training it self, and was sometimes inclined towards solving tensions by confirming from an ideological point of view the motivations of the group itself. Some passages were necessary so that group psychotherapy got the sense of a therapeutic proposal with its peculiar characteristics, which are reported here shortly. It was essentially important that a first group of therapists, who had already started a personal training path, began to make up groups in public psychiatric services; besides, this experience might also use the consultancy of external experts to public service. Later, many years apart, some factors contributed to restart this first nucleus and develop it further. One of these important factors was the organization of a departmental system constituted by the conductors of the group in the different districts what permitted to put on line some groups and their direct access to patients beyond the territorial tie, a choice which has guaranteed a more appropriate relation between the patient's needs and the type of group. Besides, this system has produced the guidelines for the indication and the sending to groups, and it devotes some monthly meetings to particular themes; the possibility of confrontation and support led with the passing of time other colleagues to start psychotherapeutic groups in accordance to interests connected to different and many requests of services.

At least, up to a certain stage, the constant saturation point of the Mental Health Centres, because of the many requests, hasn't contributed yet in a fundamental way to the importance got by the group in itself; more than other, we can say that at a certain point of the process which we have just summed up shortly, the increasing requests have certainly contributed to accelerate the change towards the most positive aspects of group psychotherapy such as the capacity for welcoming more patients in a shorter time, and the particularity of some groups set up about some specific themes to give an appropriate answer to specific needs addressed by people to this service (on the part of parents' of serious patients, young people, serious patients, patients belonging to different cultures, patients disabled by their symptoms of anxiety and patients presenting needs of belonging and activities).Thanks to this flexibility and adaptability, the group has become in the colleagues' minds a possible proposal well integrated with the needs of the service, and has lost the negative characteristics which had been attributed to it, such as the need not foresee a sufficient attention to Patients' particular needs and to be indefinite as for therapeutic specific factors.

Among the factors contributing to this evolution, the freedom of group therapists, from their own ambivalences , has been determining because it has led them to a better formulation of their proposal in relation to the needs of the team in such a way to share it with their own colleagues as a therapeutic, rich and powerful instrument. What we have just described in a synthetic manner could be defined as a process of valorization, which has happened along the time in relation to the group. We could put forward the hypothesis that in this process ideal values have been invested in an assuring way of ideal values such as strength, harmony and knowledge thus losing the characteristics of threatening of individuality, without this has caused the negation of tensions that in this way are activated (Todorov 1985; Bauman 2001) This process has made possible "the minimum of philia " for the beginning of a more convincing therapeutic dialogue (Tagliacozzo 2005) between patients and group.

The group and the Self

From our own point of observation, we have the recurring impression that the group is experienced by patients as if it was endowed with great strength and balance and just for this reason admired. The members would invest of these qualities the group in its wholeness, the members and its conductor and in some situations they could use the positive results in order to regulate internal tensions and the vital push. At the same time, the group can change into a source of delusion when it looses these characteristics and when the touch with them is lost, when the sharing of these characteristics becomes difficult. But the group can also be feared when its force is associated with threatening characteristics. These functions lead us to compare the group to the notion of Self - object- as it has been formulated by H.Kohut (Neri 1998) Kohut thinks again, as is known, of narcissism hypothesizing a different path of development, from the most archaic to the most evolutionary forms. In a first period of his theorization, he approaches the path (post note), (Ornestein 1991) already previewed by Freud (1914) going from self- eroticism to objectual love. The Self - object is a concept connecting internal and external (Ornstein 1998) underlying the importance of concentrating on the subjective experience of reality, thus resulting narcissistically invested, where the fundamental motivation of the subject is to maintain the continuity of the Self (Kohut 1971, 1978; Wolf 1988). For a therapist, his/her access to this particular way of experiencing reality on a patient's part can happen only through the method of empathy, that is as if it happened from its inside (vicarious introspection) (Kohut1971, 1978, 1984) The Self-objects- accomplish the important function of admiring and being admired and being like the Self (Kohut 1971,1978). Through these functions narcissism is modulated from more grandiose forms into more integrable forms for the individual, inside approachable ambitions and aims (Kohut 1987).

The Kohutian topic the "flow of narcissistic energies" distribute in individual in such a way to make possible the aware co-existence of feelings of inadequacy and excessive safety, aside of unmodified areas of a rough removed narcissism (Kouht 1996). The touch with narcissistic forces can breed fears of losing the relationship because of powerful pushes to the fusion with idealized images and religious figures either because of their unrealistic greatness, and emotional states of deep shame through the push of quantities of archaic exhibitionism. In the course of therapy, on the patient's part would emerge , first of all, on the patient's part the research for an experience, able to restart the interrupted development of some areas of the Self with the aim of going away from "hopeless situations" (Kohut 1984). Before analysing the clinical material we would like to introduce this theme by presenting some considerations by Kohut about the famous metaphor that Freud (1922) used in The Ego and the Id. Kohut (1971, 1978) described two different possible conditions between the horse symbolizing archaic narcissistic forces and the knight representing the Self controlling them. In a position the knight is aside the horse but in a position of distance and autonomy; in the other the knight can be horseback as if he were into touch with narcissistic forces without losing control but succeeding in leading them in more appropriate ambitions and aims.

In the group narcissistic forces can be contacted and made evolve towards more available dimensions for its members. But for different reasons this touch can be disturbed and become source of anxiety. Sometimes, the danger is not so strong and this feeling reaches the sensation to be in the hands of a "not empathic force" (Kohut 1996). Stronger anxieties are due to the transformation of ideal characteristics of the group into equally powerful attributes but which have acquired archaic omnipotent threatening forms. Instead, other dangers, are linked to the idea that the touch with these forces present in the group becomes too stimulating, up to the point of being afraid to loose any touch with reality (Kohut 1971).

We are going to show more clearly each of these possibilities with some clinical sequences drawn from three groups (A, B, C) where some pathologies of the Self are present. We can indicate in the following clinical sequence the difficulty in coming in contact with the group perceived as something which has lost the characteristics of empathic Self -object whose members try to move away from, but maintaining a contact with the conductor as mirroring Self object. In this phase, individual differences are stressed. There is some reactivity among the members instead of responsivity (Bacal 1998) and tension is high. The request for attention is pointed out as if it should compensate the interruption of the relationship with the group with idealized characteristics. The appearance of alien entities confirms the emphatic break in the area of the idealized Self- object group; the other, associated with this "negative force", so becomes too distant, something different which gradually becomes worryingly just because it is at the same time near and familiar (Berto1999; Freud 1919). It seems that the group has lost its qualities as a good force so transforming itself into a "weird" force.

In group A, made up of patients with serious phobias, personality disorders and mood disorders of average entity, a completely dangerous environment is signalled through contents concerning closed places, galleries, darkness, crowded places, entrapping (ex. The fire of Mont Blanche). All the members are inclined to address the conductor, another member speaking is almost tolerated and his/her contents recorded according to personal schemata .

Alessandro brings to attention some possibilities of construction of an empathic environment and at the same time perceived with commitment and doubt (in a dream the girl, who abandoned his brother before their wedding, urges him to buy some things for their new home). Antonietta by speaking about her youngest daughter 's difficulties to realize that Daddy went away from home, instead, signals her loss of contact with something calm and strong able to help rule emotions.

Paolo complains more and more to be compelled to spy the woman's movements, while earlier she gave herself to him with great generosity, while now he feels her evasive and distant. Rossella misses his man who permitted her to feel herself "illuminated" and Erminia says she misses Giuliano. The conductor collects this sense of "switching off" and loss something revitalizing. At this point Alessandro tells about "the phantom", present in the house where he has lived for twenty years. He says he moved things and once he knocked the chandelier down his father's head. His family called a medium, Some séances took place and, according to his story, the chain broke out when the phantom materialized, so remaining for ever inside the house .He has always spoken angrily of his father's behaviour towards his mother above all, on occasion of an extramarital relation when he was a child; once he spoke, too about a serial killer who had killed his relatives and then he had gone abroad.

The group sitting in circle, feels cemented by a foreign force, something alien, something which finds no peace and gives no peace (Freud 1912); there is the idea to have to clean up the environment, to intercept disturbing emotions. Searles (1960) thinks that a background connection exists in relation to a not human environment that he defines "closeness", and which would be characterised by "a sense of close affinity" between the processes of human and natural life. This type of relationship would maintain, together with affinity, the sense of his/her own individuality as human beings. In the cases when this border between the animated and unanimated would be lost as in the schizophrenic regressions, the relationship with the environment would be influenced by animism (La Cecla 2000).

If, in some parts, these personal experiences can be regarded as not metabolised return products as a result of a dominating "culture of evacuation" (Ferro 2002), we can put forward the hypothesis that aspects of the group have really got some changes, which have brought them to lose in the patients' minds their assuring characteristics and awake up the anxieties connected with the threatening archaic self- objects. In analysing the death anxieties Kohut (1977) distinguishes them between those connected to the Oedipal castration and those activated by the human perception of coming in contact with not human worlds as a result of the loss of contact with empathic self- objects in which we are afraid of "losing our own human Self". In a admirable chapter of his book "Forces of destiny" devoted to the ghostline personality, Bollas (1989) imagines that some patients have an inside delimited by "a ghost line" where " the essence of the Self and other states in this alternative world, where the Self of the past and the other selves live like spirits or ghosts" and are stolen. After indicating the presence in this world of a potential life he added "In a certain sense, this continuous killing of Selves gives place to an unconscious fear that the spectral inhabitants of this space one day can evade and revenge themselves on their own master".

The group will fall prey to these experiences again in the following sessions.

Alessandro doesn't come to the following session nor does Luca, who, in the earlier sessions had spoken of a friend who didn't participate to the funerals because he couldn't stand the presence of the departed. When Luca comes back he says he was afraid of Alessandro's story. Erminia underlines that in the preceding days she had been haunted by her fear that the thieves could get into home. Alessandro, on accompanying a friend, was compelled to stop at a certain distance from home because his fear he could run down somebody had returned. Luca refers that in a square in the centre he saw a mime dressed in black with a cat in his arms, what had disturbed him a lot. Armando, at Luca's request, tells again how his anxieties of being poisoned developed ten years ago. He says that may be all that is useful not to get crazy and tells of the experience of the dog and the elliptical bowl causing craziness making him/her victim of the struggle between anxiety and hunger.

Sometimes, after re-establishing a more relaxed and vital climate in the group, fear appears again that the Approach among the members causes harmful effects. Alessandro, who lives very aloof, was very glad, as he was in the park to see, all of sudden, a girl giving him her hand; she introduced herself but, at once he was compelled, because he was afraid of infection that this gesture had activated.

In the new clinical sequences, reported here, it is pointed out how the group maintained its qualities of idealized self - object but even how coming into contact can produce in the patients the sensation to be absorbed into an impersonal powerful sensation (a phantascientific computer) or to suffer the amplification of his/her own senses so that you can perceive yourselves as an insect assuming the look of the others on coming into contact (film " The Fly")

In the first session of the group B, made up of patients with serious depressions, psychosis and borderline forms and even a prolonged and intense use of drug on the part of some of them, are told two movies. Antonio says "he feels himself as a fly" hinting at the anonymous film. He feels as if he wondered confused through a sharp sensibility to sensations. In the course of the discussion about these sensations felt by Antonio, Maria, in serious depression, makes a comparison with a film whose title she doesn't remember, in which the star is "a little stupid" and Giorgio, going out of his silence, says that it is "the lawnmower Man" who then, becomes a magician of computers and Maria continues - succeeds even in entering the computer itself up to the point of becoming "pure energy". In the second session Maria, suddenly bursts onto the conversation by asking which is the border with craziness, " When "one goes out of mind?" Nello recovered many times for mystical fits, refers to have from time to time, sensations of "contact "with religious figures or to sense some references coming to him from television programmes he usually listens. Instead Sabrina expresses the idea of the trap through her revelation she is afraid of remaining shut up in the shower, not succeeding in opening the door, a fear she scan can face when she goes and have "a shower light" for her beauty bringing with her mother.

In group A, coming into contact with the great dimension of the group is represented by Alessandro through a dream where he finds himself on the back of an animal which looks like a horse but is able to stand up the ground as if it were flying, and he is really anguished to lose contact with the ground.

Sometimes, notwithstanding is present a strong desire to come into contact with the idealized aspects pf the group, to make attempts "to intercept them" patients feel they

can't, and have the sensation to be deprived from the participation to the " flow" of life (Meares 2000; Woolf 1995), "something wide and alive" (Neri 1999) remaining distant and unachievable. This can exasperate the research for how to reach a contact with the "psychic basis of the Self" (Correale 1999) and succeed in feeling greater fulfilment and integrity.

In group B, Maria says she tries to do something at home, though she succeeds little in it. She is reading for the third time a book about how "to tidy up at home", which more than give practical advice about how one can feel better, is based on an Eastern philosophy ( feng shui) according to which if every piece of furnishing has its location and is oriented towards determining cardinal points so that energy can circulate and distribute itself harmoniously causing a pleasure sensation. For example, the bed head should be oriented towards North not towards South otherwise it causes headache. She adds that at times she sways and feels some pushes to get up/stand up but then she stops.

Serena, a borderline patient, who in the past was a cocaine addict, often stands up during the sessions because she feels a strong restlessness when she thinks she might not return, as she was earlier. Angelo, a borderline, suffers because he can't draw from his own emotions and this exposes him to continuous attempts in order to find the right attitude, which can lead him in life. He moves between hardenings and a loss of control. In the course of a setting he expresses his confusion due to the fact he had tried to assume the point of view of each member in the group. Though in real life, the behaviours he adopts in accordance with the anxieties he has to face, are as an alternative, but in the group he has experienced them at the same time. But he says that in relation to his earlier attempt to integrate himself in the group he tried some years ago, where there was as in the film by W. Allen a complete and utter " Zelig Effect" , this time confusion has been more bearable.

In the group, at times, the desire for conquering again the flux of life, one has lost, is imagined as a return to the period before the disease or as a research for a structure where one can come off drugs. Erminia, instead, belonging to group A, always thinks of the earliest boy she associates to romantic images of force and beauty. She was sixteen he was her neighbour the relationship remained a flirt. Thirty years passed by, she got married and has a daughter and from time to time she has heard on the phone this man who lives now in another town. She saw him again on the occasion of a funeral and the feeling renewed painfully always because of its inaccessibility.

At the same time, the stronger is the request on the part of the members of the group of a contact with something revitalizing, containing resources and helping to establish a feeling of belonging, the more source of dangerous intrusions and destructive excitements can become, as is illustrated from the following clinical material.

In group B, Barbara tells the group a rather singular event. She had decided to install a safety system with television cameras in the house where she lives with her old mother (her father went away from home and then tried to burn it down.). The technician she had brought, cracked some jokes about the fact that a man's presence would be indispensable and once he presented well dressed and with a luxurious car (in her opinion to make an good impression). On one side she complained she had discouraged this man on the other side she lamented the technician didn't use new and first quality material and walked in an intrusive way. In a dream her father destroyed her objects and then he looked at her with scorn.

In group C, with "transcultural" characteristics some immigrant patients are reported and their efforts to get the residence permit, A patient coming from the East complains that at commissariat they had confused his surname with a lady's. A patient from North Africa expresses the effort to insert and the fear are not sufficient resources, since people emigrate even from Italy . Italian patients complain not to be accepted in some jobs for their age, or for a lack of knowledge of the language Particularly, one complains he can't be accepted by his mother in law who asked him to be exorcized because of his behaviour with her daughter who remained pregnant by him during summer holiday. If through these tensions the members express their fears not to be recognized as members belonging to the group, not to be recognized in their identity, or not to find there the resources they wished, there are some dreams representing the anxieties connected to intrusivity and destruction due to the approach to the group. Alvaro, an Italian is afraid of losing his specificity and at the same time in difficulty to give it a shape except in a different way. He had a nightmare where he was in the darkness and was afraid of some presences around him. Fatima from North Africa , came to the group for sexual difficulties ( as a child, she was exposed by her mother to a situation of promiscuity). She tells she had dreamt repeatedly to be penetrated by pens which became knives or which assumed the look of an animal with so many heads. In the course of a session she also told about a ritual called Lilah (night) taking place in his home land leading a group of people assuming special drinks to dance all the night until they lose their human look. Tommaso from the East

dreamt that a tall big man together with another shorter than him entered home through the window and put inside the bed near his wife. For different sessions he spoke about his fear of being betrayed. Then we continue talking about a future child for this couple. Then we speak about games and how media can influence sexual identification. Particularly, Fatima reveals she was worried about her little brother who has no father; he went away home, she is afraid he can be influenced by the present tendency which is, according to her, to turn into a gay by fashion. So the emerging theme is invasively through the fear of plagiarism.

Through a series of transformations, the group as an idealized Self- object, can be perceived as an "empathic force" that members feel they can use for their needs. The possibility of maintaining open exchanges, allows different styles of participation and permits to the material crossing the group to enrich itself with unexpected elements up to the point of making it more understandable. At times, all that happens more easily in the group as if from the listening of the contributions of everyone could evolve a favourable plot in itself; for ex. The return to a group of restless and enigmatic aspects, in the course of the setting through the different changes that everyone brought, turned into a kitten to adopt. Instead, other times, it is necessary to maintain a continuous and systematic activity of regulation and mirroring of serious phobic anxieties of psychotic residuals, borderline alterations and oscillations of mood, before the conductor and the group can give a meaning to the emotions they live. The group cannot replace the patient but can support him/her by sustaining the blocked functions and lightening him/her from the burden of disease suffocating him/her; it is as if the disease, through the activity of the group, "detached" a little off and this allows new openness. In this path of immersion, first of all with the most serious pathologies a little happens with patients what Kohut (1985) says about Dostojevsky 's characters in his work " On Courage". He inserts them between the Guilty Man and the Tragic Man; he says about them that even if they live conflicts to the limit of human endurance because of their sins and their weakness, the way they face suffering will give them "solidity and permanence" and the "realization of the destiny of an internal Self".

In group B, Gino always present at the sessions, complains about the effort he does to maintain balance after years of cures to face the symptoms of schizophrenia .At times he arrives an hour earlier than the session of the group. In the course of a session he tells he had dreamt of his dead father who leaned against his chest, and helped him breathe while he pretended to sleep. Maria succeeded in reading a magazine at school (after depression she carries out an administrative task) and restarting a work she began a month ago (she worked the back and now she has started the front) and compares herself with Barbara who succeeds more than her to take care of her own person , after a period when she also felt herself deprived of any force.

Nello dreams of a lady walking on the seashore wheeling a child in a pram . He has always claimed he had used drugs and other problems are to be attributed to a series of traumas , and he remembers how healthy and handsome he was as a child.

At times, towards the end of the session Gino tells some jokes about couples and sexuality in a brilliant way succeeding in creating a lively and coloured atmosphere .

In group A, Rossella says she feels better, her humour is steadier. She tells she had dreamt she was taking a journey to Tunisia with other people and a part of the journey was to be taken on horseback. In a later session she will confirm the steadiness of her humour. Some worries about her daughter have been well faced and she has succeeded in maintaining her good humour (she has usually the tendency to slipping into a state of depression, which has led her more than once to try to commit suicide). She says she wants to organize her neighbour 's party and she asks herself if she isn't in high mood.

Lina, who comes to the group for a serious agoraphobia and panic, has always been ready to answer with opinions and information, but she remained closed to the group from an emotional point as if she defended herself with an opposite attitude from a great need of contact with the group. She has ceased concentrating attention for short and when she regained to participate she revealed more receptive. Paolo tells the group he didn't know why he wants to return where there was once the earthquake in Friuli involving him as a conscript. That event changed his life, because it made him hypersensitive so much he could perceive the earthquakes in the countries near Italy and this led him to have a life with many activities on managerial executive level. At the same time he had felt since them the burden of energy which he started using to create messages though he didn't regard himself as a faith- healer. Nothing has remained of all that, except some traces in his a little managerial clothing. At the present he feels more and more deprived and has difficulty in getting up from his bed. He would like the group to syntonize on his feelings which he has had inside him since the earthquake's time. On one part, his desire can be seen as a trial through the group to come to contact with a good force helping him regulate the effects of the "archaic seismic force" and get changes this time not catastrophic but direct them according to definite perspectives as this emerges from a little confused speech about regional differences . At the same time he asks the group a function of mirroring of his catastrophic experience.

Conclusions

In our paper we developed some considerations about the evolution of psychotherapy of group in a ward f Mental Health pausing on the factors, which have allowed a complete integration in the activity of the Centres of Mental Health. In particular, we have tried to describe how the process of positive investment on the group has brought to a different valuation of the risks in the group concerning the patients' integrity, who have been regarded as an aspect to elaborate inside the group.

In the second part we reported, with the help of clinical material, some of the feelings experienced by patients in the context of their participation in the group and we tried to comment it in accordance to the perspective of narcissism by H. Kohut. The narcissistic structures of the patients can be activated in the group; if this process, on one part, can be source of tensions, on the other, can constitute the condition towards a modification of these structures themselves making them more integrated with the other parts of the patients' personality.

Post Note

For a period of time Kohut considered the Self-Psychology indicated to understand and treat narcissistic disorders. Coherently with his hypothesis of a double developmental axis, he considered the classical psychoanalysis theory signified to explain the structural neurosis. Subsequently he though that there is only one development line involved in narcissism, and the drives and their vicissitudes can be comprehended if we put it in connection with the Self such as those related to the oedipical stage (Kohut 1984, Strozier 2001).

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Giuseppe Di Leone

Psychologist, Groups Coordinator District II DSM RM/B.

Giusy Dittoni

Clinical Psychologist.

Martina Lucini

Clinical Psychologist.

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