this paper I will describe my experience in conducting two psychotherapeutic groups held in a Day Hospital for oncological patients.

These two groups are very similar. They are programmed to last fourteen sessions, with one hourly session once a week. They are both made up of twelve women patients, chosen by the head doctor and the nursing staff. Nine patients are affected with breast cancer and the remaining three have other types of cancer. The nursing staff participate to the running of the group, and take turns to attend. The only variable is the different stage of therapy achieved by the two groups: in the first group all the patients are undergoing chemiotherapy, whilst in the second group the cycle of chemiotherapy is concluded.

Dr. Gaion head of the Day Hospital and Dr. Fasolo head of the local Cittadella Public Health Service were both active in promoting these groups as a result of the need to intervene on new and different levels.

I have chosen several keywords to describe this experience.

The first word is reception .

Reception can be associated to psychotherapeutic groups for more than one reason. A psychotherapeutic group could be seen as a group that 'reacts to someone or something' . The Institution 'admits' the group to enable a new type of intervention. Thus the group becomes the model for a different reception compared to the normal interventions within the Institution's activity.

We can also consider reception as meaning a place for an experience that can give support to patients when they realize they are unable to face the difficulties on their own. Where there is an "illusion" (in the Winnicott sense), that their problems can be 'contained'.

According to Riefolo (1996), the need for psychotherapy means that one can feel that there is someone who simply listens and will always be there for that reason.

De Polo (2000) considers the need for psychotherapy deeply human and universal: a place where suffering and pain can be channelled, and where a benefic configuration is 'invented' a sort of enclosure of the self, that is felt and represented as being safe.

However, in this particular context that I am describing, it isn't the patient who makes an outright request, it's the illness that puts her in the position of need.

The therapeutic institution becomes the crucial point that not only offers the reception and the possibility of a psychological therapy in a specific institutional context (namely, an oncological ward), but stimulates reflection on a problem that is both phsyical and psychological.

Going back to the start of this project, I remember the first concrete step I took: an appointment with the head doctor of the Day Cancer Unit. When I arrived at the hospital the head nurse directed me to the waiting room full of patients sitting around the room. At first I stayed standing even though there were empty seats available. After a while I sat down too, but I felt uneasy and got up again, something stopped me from mixing with the patients. I felt relieved after I stood up, as if I wanted to differentiate myself from the others by standing. That was when I realized that reception was not at all easy to trigger off.

After seeing the head doctor, the foundation of the group became a reality, and I immediately met with the nurses to discuss the type of project that was to be started, and together we talked about the role they would be having in the group. It was obvious they would be a sort of 'cultural go-between': having expertise with the illness and chemiotherapy, and so could be a continual reference between the 'inside' (group) and the 'outside' (oncological ward). I explained how the exact number of chairs would be positioned in a circle and the importance of leaving any empty chairs in their place if someone was not present. A nurse asked: " If a patient dies in the course of the group would we leave the empty chair in its place?"

I was not prepared for this type of question and I immediately realised that they were more at home in the atmosphere of this group than I, (I was the one standing in the waiting-room while everyone was comfortably sitting down). The possibility of death was a variable that had to be dealt with. I thought, removing the chair would be to deny this possibility.

As Resnik (1972) claims, I would be hindering the transformation of a 'fact', a real fact of experience on which a thought can be constructed, into 'event' thus freeing it, and giving it a special sense in space and time.

Instinctively I answered: "The chair stays here", and I felt that I had 'sat down' at last.

The empty chair conjures up the second key-word, that could be defined as absence or even death .

The empty chair or empty chairs. are probably the most powerful image and most representative of the various sequences of this group.

Absence is everything that is left outside the group. The things that cannot be brought to the group are represented by absence thus producing dreams, images and meaning.

The two groups begin in a different way, but after proceed in a similar manner.

In the beginning, the first group (Salis 2001) is particularly disharmonious, with confusion and the cropping up of various sub-groups. It is a spontaneous and authentic declaration of their discontent. Although it seems spontaneous, for me it is above all expulsive: as if they wanted to keep out the only element that could restore order because it reminded them of disorder. They seemed to be saying: "You don't have cancer, you're not a woman, so who are you?" It was as if the protective situation triggered off their envy.

"I dreamt I was coming out of church, holding my friend's daughter's hand. When we were in the square, a ray of light came down from the sky creating a ring of fire around me. I was worried for the child but I noticed she was outside this ring, although I felt it was protective".

Valeria tells this dream in the third sesion.

It is the first time there are some empty seats, and the first time an absence is actually taken notice of.

During the previous sessions Elisa, who will never come to the group, is absent, but her seat is always occupied, once by a patient at the last minute, and the second time by another new patient.

After some associations, the ring of fire is accepted by Valeria as being protective, and represents the ring around our group. Valeria appearred to be the most frightened in the first sessions, but now she is able to bring even the most private and personal material. She recounts the dream after I bring to their attention that there are some empty seats among us, one of which belongs to Elisa.

Francesca talks about Elisa who is incapable of accepting her situation. Thus the things we can't accept of ourselves are kept outside the group. Elisa is thirty-two, the youngest of the group, and gradually comes to represent the child in the dream, but above all the group itself. When they ask "How can we help Elisa?" , they're asking "How can we help ourselves?" They begin to acknowledge that some things are very difficult to keep inside and reflect on, and they start facing these things, gradually making them their own.

A change comes about with the elaboration of the dream by the group. Bringing it to light helps to turn the elements into thoughts which in turn produce images and meaning.

The atmosphere gradually becomes more intense and trustful. The dream becomes what Corbella (2003) calls the reference "myth" in the group's development, and will be utilised often. Specially during problematic moments, this particular atmosphere of the dream will be recalled. Correale (1997) calls it the model scene, the central scene, representative for the individual and the group as a whole, that becomes internally embedded at a profound level.

After this dream, the group works harmoniously, and it becomes easier to work in the 'here and now' through which questions are posed, concerning the group and its objectives. Also, elaboration on the conclusion of the group is made, as the end becomes closer, triggering off fear.

It becomes difficult to go on holidays, or even think about it, because " it's so difficult to pack the bags".

Towards the end a sort of dramatization of disunion comes about: the dominant theme being: "where can I find a cure if I didn't find it here?". Between the ninth and tenth sessions there are many absences, only five patients attended the tenth session.

They talk about the celebration of mass for recovery, exorcism, miracles and expedients to contrast negative influences towards recovery. These themes that emerged in the ninth session are acted-out in the tenth session: some patients miss the session in order to attend a mass for recovery. The omnipotence of Padre Pio against group psychotherapy. I try to elaborate these themes in the 'here and now', but it's impossible to shift the attention to the interior group. In that session however, Adele operated the day before on reconstruction of the breast, managed to come to the group, (in her dressing-gown, with the catheter in her hand bag and without her wig), only for half an hour, but she wanted to show the group a possible way for reconstruction.

A few days later I dream that I was at a congress where I presented a paper on the film "Frankenstein". This brief fragment of my dream helped me to see what the group made me feel in that particular stage of its development. As if an omnipotent fantasy had taken me over (like a cancer) to revitalise a disharmonious body made up of different bits taken from dead bodies. I felt excluded once more, and competition also set in: what could "Frankenstein" represent if not the ambition to take the place of the Divine?

The group continues work on its conclusion, this time with all the patients participating. Starting from the "reconstruction" of Adele they reflect on important changes that have come about, above all a real feeling of trust, although still felt with a certain amount of wariness: it's right to hear other doctors' opinions; it's important to try different therapies or desire them, (chemiotherapy, psychotherapy, and also Padre Pio and masses for recovery), especially when one is dealing with an uncontrollable disease and feels so impotent.

In the last few sessions we celebrate the conclusion, managing to feel truly unburdened, having thrown away old things we don't need anymore and finally managing to pack our bags, which contain the various images expressed by the group, and in particular Fosca's last dream; ultimately she dreams of beautiful sunsets that could signify a beautiful end, but above all give meaning to the day spent together.

A year later, another group started with patients who had concluded chemiotherapy.

From its very foundation, the nurses presented this group as oscillating between being very motivated, "they definitely want to be part of this group" , but at the same time having great difficulty and resistance in accepting the proposed time and day for the group.

As in the previous group, some modifications have to be made at the start. A patient, who was booked to start isn't called up anymore, because the disease is too advanced. This was done to avoid an imbalanced situation.

In the second session Renata wants to participate to the group, even though she is undergoing chemiotherapy and will be different from the other members. She finally arrives in the fourth session. She is not the only newcomer: in the eighth session a trainee psychologist finally enters the group, (the 'institution' was unsure whether to let her attend or not). This same resistance is expressed by the group when they have to accept things that they feel as being unfamiliar.

Compared to the first group, this group is orderly, harmonious and strong from the very first session.

The group has finished chemiotherapy, and is well now. So they wonder "why am I here?" .. "the only thing I feel these days is anxiety".

"Is it aggressive therapy?" they ask, trying to find a reason for this group; they settle on the fact that getting out of the house and meeting new people is a good enough reason. This "wellness" will remain in the background for the next two sessions until two new patients will bring a new instance: Graziella, with her absence that will last until the seventh session, and Elena who feels very sick. This instance will not be acknowledged nor accepted. There is a refusal to accept the painful parts of Elena that are particularly intense: "you're the one that feels sick, not us.. you've always felt terrible; even before you got cancer".

Feeling sick is clearly rejected by all. On the other hand, this refusal is present from the very birth of the group, (the seriously-ill patient excluded to maintain parity).

They talk about cancer, but only in the past tense, the group has nothing to do with it anymore.

The group oscillates between the desire to tell jokes and get drunk to celebrate the end of chemiotherapy, and the desire to entrust their feelings to the group and let themselves go, even be afraid, without being rebuked or rejected for this.

Cancer is discussed in the present tense for the first time when Renata undergoing chemiotherapy arrives, in the fourth session. However, the acute phase of the illness and the phase of recovery seem incompatible in this group and Renata will not come back until the seventh session. She feels the group cannot help her, or maybe she's "a hindrance to its development?"

Compared to the first group, disgregation is acted-out in the first part of the group's development. This therapy is seen as being regressive: the fantasy of an illness that seemed to be under control emerges, and protection from this is not assured. At least during chemiotherapy each one had her own personal dispenser, a medicinal drip, (that the previous group 'benefited' by, since they were undergoing chemiotherapy simultaneously with psychotherapy). Now there is only one drip for everybody and they wonder if it is sufficient.

The all too-quick passing of time is menacing, the sessions finish in a 'split second', there will never be enough time. Even the part-time nurses in our post-group discussions express the same sensation: they are afraid they can do very little to solve the many problems.

The sessions continue and Graziella is still absent. Giulia, (who at the beginning, sat outside the circle of chairs near the door), often misses sessions too, representing the fear of being in a group: her excuse is a bout of 'flu, "the doctor told me to stay at home.coming into contact could be harmful. however today I decided to come anyway". The participants of the group feel that coming into contact could be harmful, but also desire to come, so as not to be alone. Nerves become strained, "I'm fed up with hearing about disease" says Angela who continues to wear a woolly cap in spite of the hot, sunny day.

The group starts to talk about new projects: going back to work: "after all this time I'm scared they're going to ask me how I am", or a weekend away from home: "I don't know if I could bear the long trip", or simply going to the gym: "the pain in my legs is so strong, I can never find the right position".

The group oscillates between desire to get up off the chair and fear of doing so.. We can't get up, nor can we sit down properly, we can't find the right position.

Apprehension emerges regarding their diversity. Will they be comprehended and accepted once outside?

Going outside the group is impossible, therefore it's better to stay here and deny the differences: whether it be man/woman, or illness/wellness. Even the nurse who uses the formal " Lei " when she addresses patients in the wards, here in the group spontaneously uses the informal " Tu ". But total denial is impossible, because diversity exists and is emphasized. Thus it is impossible to be at ease inside the group. It's like being in a sort of limbo where one doesn't know if the wound of the past is fully healed or not, but the moment to take off the bandage that protects not so much the body but the self still hasn't come about.

During this phase of the group I dreamt of standing in a big room with some girls: we were going to play ball. but when it's my turn I discover that the ball is made of stone, I can't throw it, I may hurt someone.. even though others throw balls in my direction that are stones.

It was as if I was incapable of making the session circular, of receiving and giving back without hurting the painful and aching parts. My interventions are individual: so many requests are made of me: namely, requests of assurance, linked to an inexplicable ordeal.

The image of a big cauldron in the middle of the room is created, everyone throws something in, but it's exhausting to stir it and almost impossible to amalgamate.

A nurse recalls a well-known patient of the Day Hospital who died recently and had participated to the previous group, as an example of incredible strength. In spite of an unfavourable prognosis, she managed to live many years achieving all the objectives she had set herself. The group reacts with many questions that are like hurling stones.

Of course you can live, but you can also die.

In the post-group various opinions are exchanged and this group is continually compared to the previous group. The news that a patient has just died is brought by a nurse, (the third patient to die after the end of the group). She recounts of another very ill patient, Fosca, who says: "I'm going to be the fourth patient to pass away".

The awareness that these four patients were so ill and with an unfavourable prognosis, doesn't make us feel any better. The question that comes up in this phase of our work is a real blow: Are these groups of any help, or are they just aggressive therapy?

Before the next session I go to see Fosca, the woman who dreamt of the beautiful sunsets. I find her serene, calm and strong, but above all, I observe that the group signifies an intense and important inner experience for her. I go back to work on the present group feeling a bit more relieved.

In the seventh session Graziella and Renata (the patient in chemiotherapy) return, and are received with warmth and relief.

Renata, encouraged by the group, is able to recall the whole story of her illness. She recounts the beginning: "even though a nodule in the breast was under medical control, and seemed benign, it turned out to be cancer" A sensation of "not ever feeling completely sure" pervades the group. So how can we trust the doctors and the different cures. And will this cure protect us from relapse?

Another patient tells of a twenty year old boy who had a stroke and is in coma, oxygen can't get to the brain.

They talk about nodules as things that connect and impede a normal circulation, blocking vital functions. There are nodules in our group that stop one from thinking, speaking, or saying that we have a disease. Getting better is unpredictable and the idea of a relapse is terrifying.

Graziella recounts a dream she had not long ago : "at my son's confirmation ceremony, there was a coffin on the altar, and my son who is an altar boy was turned to stone.."

She hadn't been coming to the sessions, because after the first session she asked herself: "What am I doing here? I'm well. I don't need to come to this group. then I discovered it wasn't true. so I asked if I could come back because I had to tell you."

It was a very moving and intense moment, everyone contributed, bringing their own children into the group. Graziella tells how her greatest fear involves her children. Just as her mother transmitted the tumour to her, so she is convinced she will do the same to her own children. For this reason she has never told even her oldest son who is twenty exactly what illness she has.

Graziella returns to the group because she is aware she is not well, the moment coincides with the group which is also posing the same type of question. She's trying to find a way of recounting it within the group and afterwards outside, an outside that risks to be turned to stone.

The dream indicates the transition from her initial denial towards symbolization that favours desire to explore her situation.

The empty seat, and then when that same seat becomes reoccupied, allows us to become aware of the places we occupy, and a new person among us: the psychologist.

Now we are able to ask ourselves who we really are: "we're not budding young flowers anymore", we are beginning to discover who we are, men and women, and it's also possible to start becoming conscious of our situation.

Strengthened by the presence of the group, Graziella will be able to speak to her son at last. but only after a session where four seats were empty, prompting Renata's dream.

Renata recounts: "I went to the cemetry to put flowers on my mother's grave, but soon as I got there, there were four coffins in my path waiting to be buried, I thought I would never get passed, but I managed to, in the end, I was able to survive."

In the group, the four coffins are superimposed on the four empty seats, (and I think of the four patients, three of which had died and the fourth probably in the near future). One patient observes that when Graziella's seat was empty, she felt paralysed by this fact, whereas today she felt freer to move and to think, even though there are other absences.

From that moment Graziella will always be present, becoming a catalyzing element for the group, like rain that will help turn the buds into flowers. The change is also exterior and can be seen from the colourful dresses they're wearing: they're not afraid of the absences anymore. They succeed in sitting comfortably in the group now, even the exterior transforms. Renata recounts of her neighbourhood, a semi-circle of houses, where one can always find a listening ear and a shoulder to lean on.

One can now observe a harmonious acceptance of inner experience. It becomes possible to recapture the story of their life prior to the illness, their childhood, their first menstrual cycle, their first steps into an adult world.

As we approach the end of the group, grief is elaborated for its conclusion, and the loss of different parts of the self will also be mourned, thus permitting new tolerance towards anguish. There is new capacity to observe one's body and to begin to accept one's condition and to be able to reveal it in the group and outside, at work, for instance: ". in the work-room there are fourteen of us (the same number as the group), and there's always someone that can take over for you, if necessary".

A spreading confidence of being able to rise above the situation comes about. Graziella comes on purpose to communicate this same feeling and seems upset to find so few participants. But the others arrive a little later on, they had gone to fetch Daniela whose legs were more painful than usual.

The big cauldron in the middle of the floor has become a pot where food can be cooked for a hearty meal. As might be expected, some things are still difficult to digest, but at least the cooking can be done without provoking nausea; it becomes possible to eat a whole meal, soak up the wonderful aroma and perceive the end like the aroma of new people (new identities after surgical reconstruction) thus accepting the situation, and as Luigina says: "We're not in such bad shape after all".

In the last session Angela arrives without the usual woolly cap, (worn regardless of the temperature), Manuela takes off her wig half way through the session revealing thicker hair than we were expecting.

There are many different angles from which the significance of psychological interventions in oncology can be seen. These range from, considering the illness having solely psychic origins, or the study of the psycho-social implications of the 'event-illness', or either taking into account the multi-factorial relations between physical, psychic and social causes (De Luca 2001).

Recently in a lecture, in an exchange of opinions with a 'depth psychologist', a famous genetist, after listing the organic causes of the illness and the therapeutic protocol, said, when a physician cannot help any longer, at that point, the intervention of a psychologist or a priest could be useful.

In oncology literature, one reads that help from psychology is taken seriously only when the possibility of survival diminishes.

In a group for training nursing staff held with Dr. Pozzi from the Day Cancer Unit at Camposampiero, I observed that doubts give way to serious reflection only very gradually on the significance of the illness in the light of the patient's life story previous to the disease.

In the due course of these groups, an idea of facing the illness from not only a biological point of view but from the patient's life story materialized gradually but with somewhat difficulty. Moreover, it was seen that the illness can become an opportunity whereby a more authentic contact becomes possible with ourselves, leading to a deeper understanding of past experience and the present.

The use of the therapeutic group allows the building of a good artificial social net, and demonstrates the same biological efficacy as the natural primary social net (Fasolo 2002).

In her writings Dr. Sacchi (2002) affirms: "when a person begins to assume the responsibility of his/her illness, it's a step towards taking charge of his/her own life".

The last key-word: Time

These groups are organized to last a certain time limit. Therefore the moment they start, the end is already on the horizon, in other words, the end of the therapy is an essential component of the experience. This aspect immediately determines the problem of time experienced as being insufficient. The temporal pressure is triple: groups with a time limit; groups dealing with illnesses; groups with variable aspects of reality and fantasies linked with death. Work has to continue for the therapist and the patients as if life will not last all that much longer. Since it will not last, then the problem is what can be done, what remains to be done, or what are the priorities?

This problem concerns everyone involved. Patients, group leaders, medical staff, supervisor all ask, is it really possible to tell everything important that comes to mind in a mere twenty minutes?

In the same way, it has always been difficult to organize the pre-group, or start the meetings with groups of health workers punctually: the reason is always the same, too much work, above all too much urgent work.

In the first session of a group a nurse, besides giving her name, introduced herself as, "you already know me, I'm the one who's always running", only to ask herself in the post-group why on earth she had introduced herself in that way.

The first few sessions of both the groups revolve around the theme, 'what to do', 'reacting' and 'keeping busy' . Minkowski (1971) reminds us that human beings with their actions and activity go towards the future, and actually create their own future.

Valeria is the patient that expresses this theme better than anyone else. A nurse asks: "don't you ever stop doing things? don't you ever have a rest?" . She answered no that she never stopped, if she did, who would do the shopping, the cooking and look after her daughters? I comment that "the theme of 'doing' and 'never stopping' comes up often in their interventions. I perceive different levels in this activity of 'doing'. Firstly, there's the necessary daily chores, the house and children to be seen to. Then there's another aspect that's just as vital: the reason that it's impossible to stop for a moment would mean to have to reflect on one's situation, and in Valeria's case it seems she would have to face the thought of death if she stops, and who would look after the children, who could take her place?"

I perceive an isomorphism between the frenetic activity of the patients and the staff's difficulty to attend the pre-group, that is partially explained by the nurse in the first meeting as "the one who is always running"; she is unable to stop, just as the patients are unable to stop, and Valeria is unable to stop, because for her it would mean certain death, or at least to have to face the situation and reflect on how it could evolve.

To stop means to waste time, reflecting and thinking takes time away from everything that has to be done. The time put aside for training or formation, is seen, specially at the beginning, as time taken away from work, and there's never enough time for that.

When time is experienced by the cancer patient as being insufficient, the reaction is an emotive state that induces or complete loss of interest for time, or on the other hand an excessive interest, that induces a state of utilising to the full each moment, resulting in time dominating the whole person's life.

Time is tyrannical and masters the cancer patient's thoughts and entire existence: the patient becomes "a prisoner of time".

This is the dimension of the time relationship that I found so eloquently expressed during the course of the above-mentioned groups, one is either master of time or prisoner.

Thus we can say the time factor is a fundamental element from the very foundation of these groups, consenting " shared elaboration in a relational warm atmosphere that encourages to speak about separation, solitude, individuation and" above all "death" (Corbella 2002).

In the course of these groups that I have described, the patients struggled to construct a different relationship with time. In part they succeeded in passing from being 'prisoners of time' to mastering the time factor.

In a recent convention where the question, what is psychotherapy was put, I was reminded of other working experiences with short-term groups in different and special contexts, where every now and then I stop to reflect: is this psychotherapy? .is a deep intrapsychic change coming about?

A possible answer, that could be a possible conclusion to this paper, is to consider these short-term experiences episodes of treatment, linked to all the other episodes (or desires of recovery), either in the present moment or in the cycle of life. Seen in this light, any competition I feel towards Padre Pio, holy masses for recovery, chemio and radiotherapy held in coincidence with the psychotherapy, is more easily overcome.

Another appropriate conclusion could be this quotation from Novecento by Baricco: " you're not really fooled until you have a good story and someone to tell it to", in other words, by telling your story to someone or to a group, it becomes narratable and acquires meaning, specially if the group listens to you and can transform it.

And, I would add, when the group conductor who represents the group itself, can guarantee the importance and the value of narration.

BIBLIOGRAPHY

Baricco, A. (1994) "Novecento" , Feltrinelli, Milano

Corbella, S., (2002) "Gruppo a tempo determinato per pazienti cardiopatici" , Mito Sogno e Gruppo 2, http//: www.funzionegamma.edu

Corbella, S., (2003) "Storie e luoghi del gruppo", Cortina, Milano

Correale A., Rinaldi L., a cura di, (1997) "Quale psicoanalisi per le psicosi" , Cortina, Milano

De Luca, A.M., (2001) " Esperienze e riflessioni sulla formazione in psico-oncologia" , Gruppo Omogeneo, http//: www.funzionegamma.edu

De Polo, R., (2000) "Inconscio gruppale e modulazioni terapeutiche: indicazioni e controindicazioni all'analisi di gruppo", in Gruppi, Vol. 2, n.1

Fasolo, F., (2002) " Gruppi che curano, gruppi che guariscono ", La Garangola, Padova

Grassi, L., Costantini, A., (2000) "Indicazioni e limiti delle terapie di gruppo nelle patologie somatiche", in Costantini, A., "Psicoterapia di gruppo a tempo limitato", McGraw-Hill, Milano

Minkowski E., (1971) "Il tempo vissuto", Einaudi Torino

Resnik, S., (1972) "Osservazioni fenomenologiche sull'addestramento dei gruppi di lavoro psichiatrico", Minerva Psichiatrica e Psicologica, Vol. 13, Suppl. al n.3

Riefolo, G., Amorfini, G., Andreoli, P., Faccenda, N., (1996) "La funzione di accoglienza del servizio pubblico". Prospettive psicoanalitiche nel lavoro istituzionale, Vol.14, n.3,

Sacchi, M., (2002) "L'uso del gruppo terapeutico nella cura di gravi patologie: Introduzione", in Sacchi M., "Teoria e clinica dei processi di gruppo", Minerva, Vercelli

Salis, M. (2001) "Prigionieri del tempo? Una psicoterapia di gruppo a tempo limitato in oncologia" , Gruppi, Vol. 3 n.3

Maurizio Salis

Via Belzoni 180

35121 Padova

O.E.D. ".the way in which a person or group reacts to someone or something"; "the action of admitting someone to a place, group or institution".

.