Abstract

The authors show the utility of using two important concepts together - the Position Sequence and the Model Scene - in group therapy for young psychotics in a residential institution. [Model scenes are phase-specific metaphors; they persist over time and are referred to repeatedly by the group members].
A transition is observed from an initial position of non-differentiation, to a stage of partial recognition of differences among patients. In this second stage - called "self-reflectiveness position"- the patients begin to ask for appreciation and visibility, and manifest a greater awareness of themselves; this process is necessary to the individual's development, but very dangerous for the unity of the group.
The authors believe that the Model Scene takes on different features and functions, depending on the group phase it appears in; therefore, it is a useful tool for the understanding of the position the group is in.

Introduction

In this work, the authors will try to show how useful it is to combine two important concepts: those of the Position Sequence and the Model Scene, as applied to group therapy for young psychotic in-patients living in a residential therapeutic institution.
As the authors will amply stress, the concept of phases is well known and has considerably expanded, thanks to contibutions provided by the psychology of the Self.
The concept of "Model Scene", on the other hand, was introduced by Lichtenberg to indicate an episode, over a long period of time, built by the two members of the psychotherapeutic relationship, the patient and the analyst, which summarizes in itself a type of relationship - for instance that of mother and daughter. [The model scenes that analyst and patient construct and modify during the course of analytic exploration convey to each, in graphic and metaphoric forms, significant events and repeated occurrences in the analysand's life. The information used to form model scenes is drawn from the patient's narratives, unfolding transference configurations, or role enactments. Model scenes highlight and encapsulate experiences representative of salient conscious and unconscious motivational themes. Constructed within the patient-analyst interaction, model scenes convey an experience as a 'picture' and thus are 'worth a thousand words'] (Lichtenberg 1992).
In this paper we would like to support the idea that the Model Scene takes on different characteristics and functions depending on the phase in which it appears and that, therefore, the appearance of a model scene in a group can represent a useful element in the identification of the position the group is in.
For it to function, the concept of Model Scene will be applied here in a broader sense than that intended by Lichtenberg. In particular, by model scene we wish to designate not just the narrative synthesis of a past relationship, but a highly significant and incisive episode in the life of the group which has remained strongly impressed in its memory because of its being experienced as the possible beginning of a new phase in the history of the group.

History of the group model scene

Many contributions by group psychotherapy scholars have illustrated the advantage of recognizing in the development of the group the succession of phases, meaning particular relational modes and affective patterns of the group which tend to prevail at given times.
Recently, the benefit of considering the importance of the transition from one phase to another was also highlighted within the framework of the psychology of the Self.
In this paper we would like to support two fundamental ideas. The first, consists of the the need for mirroring and idealizing, which takes on different aspects when the Self-object is mainly centered on the group (initial phase) and when, instead, it is centered essentially on the individual members (subsequent phase).
Secondly, we would like to uphold the idea that the model scene takes on different characteristics and functions depending on the position in which it appears. For instance, in the initial position, the model scene can be like a general story - a myth, a film, a legend - that is familiar to everyone and presents a universal value. In the second positon, instead, the model scene is specific to a single member, but it contains elements of identification that each member of the group can see as personal and individual.
In this paper, we would like to support the idea that also in groups of young chronic psychotic patients it is possible to identify the transition from a first position characterized by the lack of distinctions to one in which differences are partly acknowledged, considering the situation in terms of the needs for mirroring the group members. In such a position, the patients, as individuals, begin to ask for individual appreciation and visibility and show greater self-awareness, with possible self-representation.
We deemed it useful to call this second position the "self-reflectiveness position" and to try to grasp its essential aspects which, on the whole, are necessary for individual development but very risky for the unity of the group.
To this regard, we would like to point out that the model scene typical of the 'self-reflectiveness' position presents different characteristics from the ones typical of the previous phase which are useful to recognize and describe.
We will proceed as follows. We will begin with an outline of some of the many existing theories on the theme of positions/phases in groups. Secondly, we will describe the first position - that of `undifferentiation' - and the approaches adopted by the group and by the leader in tackling it. We will then proceed to describe the second, 'self-reflectiveness' position. Lastly, we will point out the characteristics that the model scene takes on in the above-mentioned positions and why the use of an adequate model-scene in the transition from the first position to the second one is an essential operative tool in overcoming this particularly delicate and difficult stage.

Positions in groups

All group psychotherapy leaders agree that in the course of the group's development it is possible to identify the succession of some positions which are both common and relatively easy to identify. On the other hand, it has rightly been observed that if the division into phases is too rigid, one may incur into the risk of finding the fluid progress of the group being overlapped by a stiff and mechanical pattern. It has also been observed that the phases can be considered as positions, that is to say states of the group, rather than steps that necessarily succeed one another, and that it is possible to observe repetitions and reversals.
It is possible to trace the concept of positions/phases in groups in many approaches that may also differ among themselves.
Within the framework of the systemic approach, Agazarian Y. (1981), referring to Bennis and Shepard and to the theory of the barometric event, identifies three main phases: the first is oriented towards the leader, the second towards the group and the third oriented towards the members of the group. According to Agazarian, the first phase is characterized by a high level of `undifferentiation', the loss of individual characteristics, complacency, a tendency towards basic assumptions, and an almost exclusive concern for the leadership function. Typical of this phase is a highly unrealistic attitude, scarce ability to work in the Bionian sense and a high level of idealization. The subsequent phase, oriented towards the group instead, is characterized by disillusionment, suspiciousness, loneliness, doubts concerning oneself and the group.
Within the framework of the approach of the object-relations theory a first phase is recognized in which the boundaries between the individuals are weak and precarious and a second phase in which the individuals begin to acknowledge barriers and distances among themselves. In the first phase - that of 'undifferentiation' - the projective identification mechanisms are so strong that the individual is made to lose the sense of his/her own individuality.
Two phases can be also distinguished within the framework of the Bionian approach. In the first phase, which C. Neri defines "Homeric", in Bion's wake, the group lives wrapped up in its own self-idealization - there is a strong reference here to Anzieu's group illusion - and there is no distinction between the individual, the group and a looming atmosphere of idealizing sacredness. In the second phase, which Neri calls that of the "community of brothers", the sense of solidarity emerges which, in turn, derives from the acknowledgment of a basic separation among human beings (Neri C. 1993, 1995).
Many group therapists have recently adopted the method centered on the self/self-object relationship, on the basis of the notions developed by Kohut. Here, too, the idea of position/phase has been enhanced. Among the many identified, the idea of a succession of moments aroused special interest: from the acceptance and appraisal of the need for individual recognition to moments - characterized by greater 'undifferentiation' and group value - in which such a need is entirely immersed in the group phenomena.
For the purpose of this paper, which focuses on group therapy with young chronic psychotic patients, we can therefore propose the following assumption: in groups of psychotic patients it is possible to recognize the succession of positions. In particular, summarizing what has been stated so far, it is possible to hypothesize that an initial position, which we call 'undifferentiated', is followed by a second one in which attempts are made to meet the personal need to be acknowledged according to one's own individuality, both by the group as a whole, and by the leader and the other group members.
We suggest calling this second phase that of the individual appearance of the self-representativeness function in each participant.
However, the beginning of this phase, both important and necessary, is characterized by strong drives towards fragmentation, the emergence of hostility and competitiveness, intolerance and resentment. Feelings seem to be less shared and this can lead to distrust and the loss of perspectives.
We will illustrate the main features of this phenomenology and ways to deal with it, with particular reference to a technique that was previously presented in past literature and elaborated with greater precision in the area of the psychology of the Self, which Lichtenberg defined as the model scene. In particular, we would like to submit the idea that the identification of a model scene suitable to represent the main features of the first position, and of the transition between the first and second position, represents a crucial stage in group work.
The concept of model scene in this particular instance is extended and adapted to the specific context of the group. In fact, reference is made not so much to the past of one individual but to a way of feeling, shared by all, which characterized the group over a very long period of time.

Patients and method

Within the framework of a target-oriented biomedical research project on the part of the Italian Health Ministry, we followed the evolution of a group of six young psychotic patients for a few years, through supervision; they were treated in a residential institute, the Istituto Scientifico Stella Maris in Fauglia (Pisa), where they met once a week on a regular basis. We shall briefly describe the characteristics of this group.
Six male patients were included in the study. The criteria for the inclusion were as follows:
a) diagnostic characteristics consistent with DSM IV diagnostic classes as included in section "schizophrenia and other psychotic disturbances", except for one case that showed "Schizotypal personality disorder"; and the ICD10 categories included in sections F20-29: "Schizophrenia, schizotypal syndrome and delusional syndromes" (excluding category F23: "acute and transient psychotic disorders");
b) onset of disorders in adolescent age (14 to 16 years); the patients' average age at the beginning of group therapy was 22.7 (range: 19.3-25.2); a cognitive evaluation conducted on all of the patients showed an inconsistent profile, with I.Q. borderline values and minor deficits.
All patients were on neuroleptics and carbamazepine (as mood stabilizers) and they had been at the Institute for less than five years. The therapy group met for approximately two hours a week on a regular basis and was led by a neuropsychiatrist as the therapist and by a co-therapist. The clinical material was regularly reviewed once a month.
Extensive literature on group psychotherapy with chronically psychotic patients has revealed, with a great deal of observations and details, the specific and enormous difficulties met in conducting this type of groups (Correale A. 1995).
Without going into further details, we want to mention two characteristics typically found in this peculiar situation: fragmentariness and concreteness. The former has to do with the well-known tendency towards interrupted communication sequences, with divergence intervals and easily interrupted subject-matters, which takes an emotional toll on the therapist and makes him feel somewhat useless (Kibel H. D. 1990).
The latter concerns another equally well-known tendency to minimization and simplification (Marty P. - de Uzan M. 1963), with excessively belittled meanings, flattened emotions and a tendency to avoid emotional sympathy. The annoyance and tiredness that the therapist often experiences is linked to the feeling of being surrounded by floating fragments, with no order or rules, provided with a colliding force but without any clearly developed communicative value (Scala V. 1989).
There are effective ways to deal with these problems although over longer spans, as this experience has proven useful:
1) the method of thematic amplification (Corrao F. 1979). According to this technique, the therapist is concerned not so much with investigating how individual members interact with each other or the symbolic value of their communication, but he/she rather focuses on making continuous connections among the various contributions, so that the themes presented may develop instead of fading away and getting lost. This function - which should be gently carried out through specifications, emphasis and questions, requests for clarifications or unintrusive associations by the therapist aiming at making communication flow smoothly - will, therefore, gradually become the vicarious function of the group's ability to synthesize and make associations, habitually hindered by the fragmented organization of the Self in each individual member. The therapist will act as an active interlocutor, to support communication, without almost interpreting it at all; he/she will collect every single detail and piece of information told by the patients and seam them together endlessly, thus carrying out an uninterrupted work of connection of the various contributions.
2) Another technique is "controlled narrative" (Neri C. 1995): the therapist will re-present broken-up, blurred fragments from the group in the form of more easily readable stories, characterized by common affectivity, and will suggest that the group comment on them. Thanks to the two above-mentioned techniques, the therapist will play the vicarious role of the group's ability to synthesize and associate, which is undermined by the fragmented organization of the Self in each individual member. Supervised integrative and symbolic work is carried out and used during the following sessions to increase empathic availability. Thematic amplification and controlled narrative offer the advantage, in our opinion, of emotionally approaching the patient in the group neither too directly nor too involvingly.
3) The third technique is about evaluating fixed roles (Yalom I. D. 1985, Stone W. N. 1992, Agazarian Y. 1981). As group therapists know very well, the rigid roles and petrified, never-changing 'masks' that often appear in a group, taken up by patients to protect themselves from particularly distressing experiences or emotions, and that are never challenged by the group for fear it should rekindle or face unbearable or chaotic anxieties, are often the self-pitier, the monopolizer, the lavish one, etc. Such roles are particularly strong and frequent in groups of chronic psychotic patients; in order to deal with such situations, it may be useful to consider these roles not only as natural defences, but also as attempts to master a group assumption, i.e. that, behind each role there is a corresponding ideology, an outlook on the world that tends to drag along some followers or the whole group. In such cases, "making explicit" the richest philosophical, existential, ideological implication inherent in certain statements or attitudes may be useful, encouraging the whole group to comment, to reflect and discuss these implications, more than the role itself.

The first position in a group of young psychotic patients

For the purpose of this paper, it will suffice to remember that throughout the entire first phase of the group work, which lasted about a year and a half, an atmosphere of strong `undifferentiation' prevailed. With this term we mean to define a situation in which none of the participants felt capable of using the pronoun "I", in other words to provide a first-hand account of experiences or events or impressions. Instead, the prevailing approach was anonymous, based on references to vague sensations, films, legends, songs, in other words elements common to the entire group rather than specific to just one member.
A second aspect of this first phase of the group work deals with the fact that in the group some shared emotions which were common to all the members of the group tended to prevail. Such emotions were mostly centered on the description of moods, which, being common, seemed to help communicate to the members a sense of sharing and belonging. The most striking aspect of this phase was that the dominating emotions seemed to be connected to very primitive and basic moods, centered mainly on one's place in time and space, on one's existential coordinates. The members spoke mainly of a deep severance between past and present; the present, which had been severed violently from the past, was described as a state of suspension, uncertainty, absence of planning, intense if aimless - vitality. The past, instead, was experienced as a lost and inaccessible world, a sort of archeology comprehensible only to few experts, but otherwise with no key for its interpretation.
During the first phase, the interventions were mainly on the level of connections and organization, thematic amplification and narrative fluidification, without seeking or exposing meanings other than the ones expressed.
The most significant representation of this first period was a phantasy, brought by a member of the group, but embraced by the group as a whole, of a journey from ancient Egypt to the contemporary world for which it was necessary to all board a spaceship capable of traveling into the present time.
The scene described contains many significant factors. First of all, time is expressed in terms of space, in other words the past is a place - Egypt - and not a moment in history.
Secondly, there is a definite severance between past and present on account of which an imaginary means of transport - the spaceship - is required. Lastly, the past is a heap of archeological remains, fascinating but accessible only to experts - archeologists.
We believe it is possible to consider this representation as a model scene, even if rather peculiar, for it contains in a visual form a general aspect common to all, which implies a relationship, even if specific: the group is the spaceship that allows us to come back from the past, and "a heap of archaeological ruins" is an excellent description for the psychotic patient's self-experience. The fact that the past is only accessible to experienced archaeologists describes the patients' willingness to be helped by the therapist and suggests a good level of therapeutic alliance (H.D. Kibel - personal release).
As we said before, the concept of model scene in this particular instance is extended and adapted to the specific context of the group.

The second position in the group

Slowly, towards the end of the group's second year, intense personal passions began to appear. At first, a strong need for personal acknowledgment arose - of the type "you have to speak about me and to me" - accompanied by a feeling of jealousy towards the other members, which was never clearly expressed but could definitely be felt. Furthermore, the theme of one's personal history became central and everyone recalled events in his/her own life, which now needed to be commented upon and acknowledged and were no longer merely a contribution to a prevailing emotion.
In particular, one patient, René, proceeded quickly to a phase of self-identification in the group, no longer accepting to serve as the receptacle of the projection of more undifferentiated and disaggregated parts of the others. Throughout the first year, René experienced a sort of "total passive retreat" which led to regard himself as disaggregated and lacking any identity. In the second phase of the group work a more integral, though threatened, Self arose which recovered an identity of its own and was distressed by the fear of losing it again.
From a session in May `98 René stated: "In the past I did not have someone who supported me, fed me ... I didn't have anything good to eat ..." Then, answering another patient with whom there had previously been an intense confusing attachment he added: " ... but I'm talking about myself, my parents; you talk about your own business ..." Immediately after this he left the room but came back later. This was a typical example of how the group of patients was moving towards a phase of greater contrast, jealousy and requests for personal acknowledgment.
We assumed that an important element was to be found in René's statement and behaviour, hypothesizing that an initial identification phase was appearing in him, with elements of self-representation and self-description as a subject/child, undernourished or malnourished in his own original matrix, in his own basic relationships. A higher level of self-awareness, as well as a self-representation ability, which some patients like René were acquiring, induced an element of potential fragmentation in the group, which slowly but inevitably led to arguments, outbursts, clashes, fights. Some members left, others became anxious and edgy.
This second phase was tackled by searching for new unifying scenes. The group no longer sought to identify common emotions but focused on specific personal images with a collective value, which served as a vehicle for prompting unity among the members. We might say, stretching Lichtenberg's definition a little more, that the technique consisted in seeking model scenes that were sufficiently effective to shed light on what was happening ; capable, that is, of representing the specific type of individual-group relationship which prevailed at that time. An example will make this assumption clearer.
At one of the group sessions a patient, Andrea, arrived late and as soon as he walked in, another patient, Carlo, left the room. Andrea, feeling overcome by anger towards Carlo, entered into a state of psychomotor agitation and managed to say that he felt green with rage, just like the hero of a science fiction movie, the 'Incredible Hulk'.
This association led us to identify Andrea's attitude with an attempt to communicate to the group that, at certain times of impotent rage, he turned into "Hulk", which, in the film, is the transient state of David, the scientist, who swallowed some chemicals by mistake as he was experimenting. Hulk is a character who defies control, who fights against evil and protects the innocent. The image proposed by Andrea to the group suggests that the patient is seeking an identification of himself, but that he has poor impulse control; thus the image of the Hulk is both perceptive and self-descriptive (H.D. Kibel, personal release). It seems important to emphasize the time-related and oscillating element that this description conveys: only in certain times of impotent rage does Andrea's human identity turn into Hulk.
To cope with this atmosphere of unease, some patients pretended nothing had happened, others withdrew into their private phantasies. The leader observed that very different languages were present that day, that there was no harmony, and she suggested that they engage in a time of sharing, reading out loud the poems that one patient had brought to the group. The poems were considered a second attempt, activated by the leader this time, to provide a collective vehicle by means of which to control Andrea's anger, and at the same time offer him a vehicle for sharing his anger.
The atmosphere then softened, the patients tried to find the one poem that best expressed Andrea's mood. Andrea was uncertain, however. He was afraid of not being able to control himself but, at the same time, continued to beat his chest, like the Incredible Hulk, making an effort, both humorous and desperate, not to offer the group the spectacle of a man overtaken by his emotions. In other words, Andrea tried to portray himself, as it were. At a certain point, the co-leader imitated Andrea in an affectionate way; he looked at her as if he were gazing into a mirror and smiled.
Faced with this scene, the leader then suggested each one in turn read out the poem entitled "The Mirror" and discuss it together ("I look at myself in the mirror, I feel young and I feel old and as I look at myself I realize how imperfect I am").
This seemed to provide the group with a new common ground. Andrea calmed down and smiled again. Andrea's anger had dissolved without having been dealt with directly. No-one used the term 'jealousy' but everyone, including Andrea, knew that that was what it was all about.
All the members of the group commented upon the poem while the leader observed that the purpose of the mirror to help one to look at oneself as one is overtaken by an emotion, and that it reflected and made one think, but that it also served as an image in which everyone could see something.

Discussion

Thanks to the therapeutic experience conducted for a few years on a group of young psychotic patients hospitalized in a Rehabilitation Institution, it seems we can state, consistently with literature, that the group went through different positions, which, in our opinion, should not be seen as sequential phases in a rigid pattern, but rather as phases or positions that may be lost and re-acquired, depending on the state of fragmentation or higher integration of the Self, allowed by the patients' psychotic pathologies.
Some distinctions could be made in the group between the initial phase, which lasted approximately two years, and a subsequent phase, in which "model-scenes" were produced by the group. In our opinion, this is related to the beginning of an identification phase and to a higher integration of the Self in some patients: first of all, in René, then in Andrea and Carlo.
In the beginning an atmosphere of strong indifferentation prevailed in the group. Each member made the effort of bringing sensations, memories, events and relational scenarios connected with the latter's impact on the Self into the discussions.
If the therapist is aware of the vicarious role of "thematic amplification" and develops this role gradually, together with "effective narrative" and "roles made explicit", he/she will see that, of all the scenes each member will put forward, some will contain emotional, imaginative, phantasmic stepping-stones which will allow other members to contribute in the enrichment of that scene. In other words, the scenes that seemed to fragment the group tended to be more and more largely shared, as each member imaginatively and emotionally placed himself within them. Such scenes, as our experience also demonstrated, are not very often produced, but are the outcome of a long preparatory work and the place where all the scattered fragments and elements finally seem to find a completed and readable form (Correale A. 1991). Here, then, the model-scene event also takes on a group value, since it represents a sort of collective place. Model scenes are metaphors that are phase-specific, but they are also much more: they are metaphors that persist over time and are referred to repeatedly by the group members. In this sense, they have an organizing capacity and give the group an identity of its own.
In the group experience we described above, this tendency was prompted further by two factors. First, the fact that it was a group of in-patients that met once a week. This made it possible to somewhat release the group from daily problems, which were dealt with on other occasions, and turn the group session into a sort of "play room".
Secondly, the patients were all very young, although chronically ill. Therefore, the trauma was still rather recent and could be visualized quite vividly, although it was already considerably estranged by the processes of chronicity.
Finally, it must be stated that the identification of the communicative value of the scenarios occurred primarily during the supervising stage, in other words after the session and not in the presence of the patients (Correale 1996).
In the initial position, the model scene took on the appearance of a story - a myth, a film, a legend - familiar to everybody and provided with a universal value, just like the metaphor of the Egyptian archaeological ruins.
In the second position of the group therapy, at the end of the second year, each patient achieved a greater level of self-perception and self-representation within the group as well as a more detailed self-description in relation to the beginning process of identification and reintegration of the Self. The scenarios became more and more personal, each patient acquiring more depth, like sculptures on a bas-relief that stand out more and more clearly against the background and create increasing three-dimensional and chiaroscuro effects, while threatening, at the same time, the consistency of the group. Individuation in the group runs counter to group unity, but the model scene enables both to occur simultaneously.
The use of an appropriate technique during the shifting stage from the first to the second phase is a basic operational tool essential in overcoming this crucial moment; we support the assumption that the identification of a "new model scene" is therapeutic during the shift. In particular, an intense subjective experience, in this case Andrea's angry jealousy, is shared without being directly stated, as if it were observed from a mirror in the distance, making it less harsh and indirectly felt. The co-therapist imitates Andrea, as if she were affectionately showing him what he is like when he turns into Hulk. Using an adequate technique in the shift from the first to the second position is an essential working tool for the overcoming of this particularly delicate moment. The new technique is now to use indirect modalities which may show the existing emotions to the group and its individual members without naming or explaining them directly. Thus, the group leader enacts a sort of representation of emotions, with great empathy and affection. This makes it possible to distance oneself from feelings that are too intense and dangerous. A new technique today is, for example, to 'show with affection' using indirect tools: reading poems that suggest emotions to the patient, for instance, naming them indirectly, without explaining them.
Like in the myth of Perseus and Medusa, one cannot name and directly tackle the subjectivity of an emotion that is very strong, for its acknowledgment on the individual level would entail a petrifying and lethal effect, like the gaze of the Gorgon. The group requires different techniques, that provide indirect knowledge, that is a representation of other people's emotions, analogous to the mirror scenario, where distance turns them into more tolerable and shareable feelings. These techniques may help to overcome the risk of fragmentation within the group and to foster a new phase of self-awareness in every individual in the group.
The mirror scene, as we mentioned above, cannot be defined as a model scene strictly speaking, since it does not refer to a past event. It rather refers to a specific and stable configuration in the group. There was an emotion specific to Andrea, his anger which was brought to the group and made known, while stila remaining personally his. The group returned it to him in a form that he could reabsorb without losing his control.
The scene also contained a retrospective value. In the past, Andrea's rage petrified other people and consequently himself. Now, he could express it in a way that can be shared by others. The group acknowledged that Andrea's jealousy was both individual (Hulk) and group-related ( his anger that touched each one of them).
In this second phase, the group's function as a mirror, an animated and understanding vehicle for individual differences, remained a single container in which everyone could recognize and reflect him/herself but could also return aspects of their subjectivity to the patients in a bearable and no longer explosive form.

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Antonello Correale M.D. Psychiatry; Via Cavalier d'Arpino 26, 00197 Roma Italy

Patrizia Masoni M.D. Child Neuro-Psychiatry; Scientific Institute "Stella Maris", Viale del Tirreno 331, Calambrone, Pisa Italy