The application of the psychoanalytical model to the institutional health framework has fuelled new reflections on the interconnections between the establishment and retention of an analytical setting and the organisation hosting it. When an analytical setting is set up within an institution it generates specific dynamics which are going to be analysed in the present article.

Since the terms "institution" and "setting" may take on several meanings it is useful to clarify that the former refers to Public Health Services - Departments of Mental Health and Services for Drug and Alcohol Addiction - and to Therapeutic Communities, while the latter refers not only to the whole of the analytical structural aspects - frequency and length of sessions, meeting procedures and prohibition to meet in a different venue - but also to the analyst's psychic availability to receive the analytical situation, that is the mental setting in a Meltzerian sense (Meltzer 1967).

The need for an analysis of the relations between the analytical setting and the public institution is inspired by the considerations of authors such as Bleger and Correale who have underlined the close links between the psychoanalytical setting and the institution in terms of constitutive structures and dynamics. In particular, Bleger (1966) has written that: " A relationship lasting for a number of years and keeping to the same rules and attitudes is nothing less than the very definition of an institution. Therefore, the setting is an institution where phenomena called behaviours occur ". Consistency, regularity and predictability turn the setting - as well as the institution - into a container where elements of the mind which escape the psyche may be deposited. According to Bleger the setting and the institution become the depositaries of the undifferentiated parts of the individual and the group, the "ghost world" ( ibid ). " The setting is the most primitive part of the personality, it is the fusion between the Ego, the body and the world. Its immobilisation determines the shaping, the existence and the differentiation of the Ego, the object, the body's scheme, the body, the mind ." (Bleger 1966). Hence the institution - as well as the analytical setting - may be seen as a big container with numerous psychic functions.

Bleger's intuition has been expanded on by Correale who believes that " the institution - as well as the setting - may be defined in very broad terms as a relationship - or series of relationships - lasting for a long time and regulated by shared rules. This definition implies first and foremost a structuring factor of the relationship, linked to its very existence, to its continuity over time, to its being a process, [.]; it is a factor related to the physical nature of that continuity, to the regular presence of another person [in the setting] or of other people [in the institution]" (Correale 1999). Thus, Correale feels that regular proximity is an extension of individual sensoriality, irrespective of the single events occurring among the members of the relationship. " The individual immersed in the setting or in the institution gradually learns to consider his institutional perceptual world as a sensorial world shared by the other members, who perceive it as a single perceptual and sensorial structure. Every time the member of an institution or the person analysed in the setting re-enters the shared space he finds himself in a habitual space already filled by his imagination with a shared sensoriality. The space becomes our space, the depository of our lives and no longer of a single life, or rather the person in question activates a fantasy linked to the non-distinction between I and we " (Correale 1999).

The foregoing clearly suggests that when the analytical setting is implemented within an institution the institution's organisation and dynamics inevitably exert an influence on the structural and symbolic dimensions of the setting.

First of all, it is important to reflect on the structural and practical dimensions of an analytical setting carried out within the public service. While in a private situation the therapist is able to furnish the consulting room and make it comfortable for the patient, in an institution it is not always possible. Rouchy (1998) describes the experience of an analysis whose setting was located in a " room used as a corridor giving access to other rooms ". Semi (1985) describes the chairs used in psychiatric wards and underlines the importance of receiving the patients in a comfortable environment: " Having comfortable chairs with arms and covers simply tells the patients that we know perfectly well it will not be easy for them to express their things, but that at least we are trying to put them at ease. [.] It is useful to remember that the purpose of the famous couch is patients' physical relaxation to enable them to observe what springs to their minds ".

Some of the structural elements of the setting differentiating the analysis in an institution from that in a private situation are the lower frequency of sessions, the face-to-face position, the lack of payment and the overall duration of the treatment (Bolelli 1991; Amodeo et al. 1991).

In a public context the frequency of sessions does not exceed the number of two per week. Amodeo and other authors feel that the low frequency of sessions per week has two possible consequences. On the one hand it may favour a slow and gradual approach to the psychotherapeutic dimension, while on the other it may lead to a stiffening of the defence mechanisms, thus hindering the elaboration process. (Amodeo et al. 1991).

Although in certain cases institutional psychoanalysts may have a couch at their disposal, psychotherapeutic sessions - including analytical ones - normally occur in a face-to-face position. This provides a constant visibility of facial expressions and gestures and a continuous exchange of looks which increase the incidence of sensoriality and enable the patients and the analysts to maintain a high degree of contact with reality. However, it is also true that direct eye contact may provoke regressive and fusional fantasies which may be perceived as a threat to the individual's integrity (Bolelli 1991; Amodeo et al. 1991; Grasso 2001).

While in private situations payment is part of the setting's background - because it is at the basis of its structuring - in the public context, when the treatment is free of charge, its being free " may threaten neutrality and lead the therapist to have omnipotence fantasies, gratification drives and excessive expectations of patients. Free treatment may generate guilt feelings and/or self belittlement in the patient, and may contribute to the creation of a troubled and insoluble dependence " (Amodeo et al. 1991). However, free treatment does not always spoil the setting. For example, adolescents may feel more independent of their families while psychotic patients do not consider themselves as being the subjects of their demand for treatment. Hence, the symbolic meaning of payment is inaccessible and unusable and they tuck it away in the area of rejected environmental objects ( ibid .).

Bolelli (1991) describes the institutional difficulties as regards sessions' stability in terms of time and space, professional secrecy and "setting manipulation" by nurses and/or administrative staff. She affirms that the main difference between an institutional analysis and a private one is that the institutional analysis, apart from being free of charge, also includes the other members of the institution who do not always respect the setting because they do not recognise the rigor necessary to the analytical situation ( ibid. ). In this regard, some authors have underscored that in a public institution the need for respecting the formal conditions of the analytical setting is to be recognised not only by the therapists and their patients but also by all the other workers.

A psychotherapist cannot automatically apply private models to public situations (Ardizzone & Carbone 1991) where the setting not only needs to be recognised and shared by the service but is also influenced by practical factors such as rooms availability, timetabling and the need to cover a diversified range of patients who are different to those of the private sector.

With reference to the total length of treatments, psychotherapy in the public service tends to be focal and predetermined in length because patients pay for a fixed number of sessions at the local health unit and because the number of patients is high in proportion to the number of psychotherapists in the service.

On this basis, group psychotherapy in institutional situations is an effective solution both in terms of space availability and in terms of time for patients needing longer treatments. However, group settings in the public service are subject to specific influences too. The synergy between analytical group sessions and the receiving institution has been summarised by Rouchy (1998) who affirms that " between the setting and the institutional framework a 'job' is carried out - often without the knowledge of the therapist - and it needs to be considered outside any defensive preconception or ideological censorship. The institutional framework enters the setting and directly influences the internal dynamics of the group. [.] The institutional framework determines the nature of the demand, the relevance and the field of the setting ". Therefore, also group setting is subject to adjustments to coexist with the inevitable influence of the institution.

In this respect, it is interesting to understand what the consequences are for the fundamental rules of discretion , abstinence and regular presence in analytical groups.

It is also reasonable to inquire into the limits posed by these rules for the members of a group meeting in a Therapeutic Community or in a Department of Mental Health. In this case does discretion specifically regard the members of the therapeutic group or does it apply to the whole service? A rule of this kind can only be established if patients do not have any contacts with each other outside the group setting. In an institution such expectation is clearly a paradox.

One of the distinctive elements of the analytical group setting within the public service is the waiting room ( ibid .). The rule of abstinence is undermined by group members meeting before sessions because they inevitably start talking to each other creating a sort of pre-group. This problem can only be solved if verbal encounters in the waiting room are then reported at sessions, where they can be interpreted and contained by the analyst ( Roussillon 1988).

Discretion and abstinence are also influenced by the fact that group members not only meet outside sessions but may also participate in other types of groups, especially in residential communities.

Also the meaning attributed to regular presence varies according to the setting venue. For example, in certain services nurses are expected to remind patients about their next group session, thus acting as intermediaries between the group and the setting and influencing their contacts through a series of behaviours. They may fail to inform either the therapists or the patients that a session has been suspended, arrange a check-up timetable coinciding with sessions or alter patients' state of consciousness by giving them psychotropic drugs which reduce their wakefulness and ability to participate in the group.

We may now focus on the mental features of the analytical setting and the institution hosting it.

In the public service the setting always includes reception interviews, waiting rooms, familiar figures to turn to. Hence, in an analysis or a psychotherapeutic treatment the patient does not develop a relationship with the therapist alone during the analytical time and space but also with other professional figures in other institutional times and spaces.

These institutional features are perturbing elements of the analytical process since factors generating anxiety in the patient are left out of the analytical room and stay " in the waiting room, in the corridor, which become tangible pockets where elements not yet able to enter the relationship are acted on or deposited " (Amodeo et al. 1991). Roussillon (1988) calles these spaces "interstices".

According to Roussillon everything which cannot be introduced in the setting of a session, everything which maintains a potential nature in the patient's psyche finds a peripheral space in the interstice, thus protecting the patient - and sometimes the analyst - from the passage to the external act of the analytical process. In this case past experiences, meanings and dynamics settling in the interstice may either escape the analytical process or find an entrance to the analysis in this offshoot of the setting. The institution provides the patient's resistance with tangible escape routes located in a "transitional time and space" which requires analysis ( ibid .). Roussillon underlines that the patients who wait for the end of the session to start talking or to convey a significant past experience find the time and space to express the unsaid in the interstice. The institutional psychotherapist should avoid carrying out an "intervention" in this situation since "the interpretation is to be confined by right to a structured therapeutic setting: the process cannot be separated from its setting and the intervention on the process cannot be separated from its structural conditions" ( Roussillon 1988).

Also in group therapy the mental dimension of the setting acquires a specific meaning in a public institution, where group members might participate in the room preparation shifting furniture and forming a circle with the chairs. This ritual activates specific dynamics which go beyond the time and space of a self-built setting and need to be metabolised and contained by the analyst's mind. Thanks to his consistent behaviour and to the predictability of "his" rules the analyst determines the passage from real chaos to the artificial order of the setting, from the inside to the outside of the group. Therefore, if the therapist usually looks at group members in the face when they talk he should always be consistent with such behaviour, just as he should always keep to the same style of clothes. In this regard, it is useful to underline that while the variations of the structural setting in an institution do not often depend on the psychoanalyst, who is more likely to keep them under control, the psychoanalyst's mental attitude may change unconsciously according to the events experienced by the group. It is thanks to the group's feedbacks that the psychoanalyst can become aware of such changes.

Conclusions

The analysis of the structural and mental elements of the classical - dual - and group psychotherapeutic settings in a public health situation shows that the institutional setting does not coincide with the purely psychoanalytical dual or group settings.

Taking into account the tangible limitations of these settings some authors inquire into the real applicability of the analytical setting to the institutional situation (Fava 1992; Bolelli 1991; Laszlo & Ballerini 1992). " In the public service the various therapeutic settings - dual, group, etc - are in close contact with another setting given by the norms, regulations and customs of the organisational structures where they take place. Thus, the situation is characterised by a kaleidoscopic multiplicity of interrelated and intertwined institutional meanings emanating from the individual and/or the service " (Fava 1992). According to Fava an institutional framework may determine the formation of two settings, a "thought" one and a "non-thought" one. The former " is constantly put to the test by the halo effect of the institutional rules which seem to become the containers of the internal attacks on the setting by the patient and the therapist " ( ibid .). The latter, which is expressed by norms and regulations, " provides for an effective and indispensable containment of symbiotic and non-integrable nuclei at a given time. Thus, the nuclei may stay in the depository of the established part of the institutional rules " ( ibid .). By establishing all the setting rules from the outset, without having to face up to new situations in a state of emergency, the setting - a necessary constant for the observation of analytical variables - can be thought out. In view of the foregoing the dissemination of a "psychoanalytical culture" within the institutions is desirable. It can be achieved by providing service workers with training and information about the need to respect psychoanalytical time and space. However, such activities are not always feasible. Analysts, therefore, strive to "defend" their settings through adaptive strategies. The impossibility of complying rigorously with analytical technique in an institution reflects a problem shared by psychotherapists working in the public health sector, that is the choice and use of a theoretical model of reference (Amodeo et al. op. cit. ). According to some authors the solution is not to take refuge in ready-made techniques but rather to keep the thinking function active - however difficult it may be - by accepting the complex comparison among different models and among these models and different clinical practices (Amodeo et al. op. cit. ; Bolelli op. cit. ; Fava op. cit. ) . In an institution the setting is hardly ever a mute framework either for the patient or the therapist because they are permanently immersed in the "background noise" of their psyche and of the public service. Hence, in an institutional situation it is important to build a mental space able to receive the patients and to establish a rigorous therapeutic contract with them taking into account their time and the institutional dimensions (Amodeo et al. op . cit ).

In this light the analyst's ability to "defend" the setting is proportional to the clarity which mentally defines and structures his own internal setting. The institution's anonymous dimension requires the therapist to have more of an internal availability than in the private sector to receive the dyad or the group intimately, and a more solid awareness of the reference model. This model ought to be flexible to adapt to the institution without neglecting the rigour which provides the setting with its therapeutic function within the analytical process.

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