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Clinical and training in Homogeneus Group |
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Of late group psychotherapies have reached a new stage, in which 'traditional settings' have been paired with others emerging from new theories and changed needs. In general by 'settings' we mean to include both mental and operative ones (set and setting).
As stated in other occasion, we want to first of all stress some general considerations before taking into account what is the theoretical and applied thought we have been developing in the last few years at the CART Study Centre directed by Zucca Alessandrelli. The validity and specificity of group settings has been largely acknowledged by the general culture and analytical institutions thus allowing the 'group' to start vigorously entering into Services as well private practice. Due to economic reasons (in terms of the reduction of time and costs promoted by the new logic of Public Services) there is a tendency to generalise and make a greater use of group settings which however run the risk of being devalued of there utility. That is to say, a certain simplification is too often observed, with the possibility that Group Psychotherapy may expand in a chaotic way and thus implode loosing its specificity and its therapeutic potentiality. This phenomenon, for many aspects has already happened for individual psychotherapy, especially in the so-called therapeutic communities. Moreover, the word 'Psychotherapy' should be used with caution in that many group and individual therapies are so called, but in our opinion, the word 'psychotherapy' can only be used if it truly leads to inner change. Many proposed therapies presented at conferences don't appear to fall under the category mentioned above (i.e. of the inner change) but rather experiences (especially the short ones) that have their own limited albeit useful objectives. In the same way the so called self-help groups are not concerned with a deep inner change and development but rather have a tendency to become group systems of reactivity and in some cases of psychological superficiality. However they can non-the-less guarantee a welcoming atmosphere and psychological holding which may be useful for the remission of symptoms. So why, use group therapy? When is it appropriate? And which type of group? Most definitely the group setting represents a psychotherapeutical and experiential moment of great efficacy. It may even be able to 'surprise' (and therefore conquer) 'today patients'. It is now apparent that many professionals are adopting short-term group therapies, often in so called homogenous settings. Even the concept of homogeneity, appears to be open to misunderstanding. A homogenous group could be made up of patients affected by the same organic, psycho-organic or psychological pathology. Homogeneity, in this case, is a diagnostical attribute. For example homogenous can be a female or male group, i.e. based on gender. Or a teenage group based on age. Furthermore, a group can be homogenous because of an event that is shared by all its members, e.g. a trauma or an intra-psychological conflict which unites its members. For our purpose we think that it's more important to conceive of the concept of homogeneity as the psycho- structural and intra-psychological level of the patients on which we want to intervene. This will be better understood, when talking about our own patients. We referred to them, just a few lines above, as 'today patients', that, in our opinion, generate 'new questions'. These in turn stimulate 'new answers', when remaining alert to the intra-psychological changes of generations both in a synchronic and diachronic sense. For these patients, Zucca Alessandrelli and the Study Centre, were the first to devise a new model of short term therapy, called GRF (Group for the Recovery of Functions). This model was realised by those who have spent many years researching at the Study Centre. The first studies were carried out in a few territorial Services of psychiatry (1999) and in the context of drug addiction (1999-2000). Some works concerning these experiences have already been presented, whilst the extension of the original idea concerning the basic principles of the clinical intervention, which is coming from Zucca Alessandrelli, is now in print. Emerging from these experiences we'd like to bring some important concepts to your notice. First of all it is necessary to diagnose the patient's psycho-structural level. Namely whether he/she is in a pathological or a pathogenic stage. In the former situation the patient has an in-built pathological organisation that might show up in a syndromic way by means of neurotic, psychotic, or borderline expressions. In the latter case the patient exhibits symptoms revealing a malaise that has yet to develop into a pathological structure, and therefore expresses itself in a sharp, often sensational way. This may lead clinicians to a hasty and emotional diagnosis, causing the patient to develop a chronic state. The next step is to discover the patients' skills in modulating and mediating the inside and the outside, i.e. his Self, which if fragile, is unable to use the psychological apparatus. This normally, should work as a protective shield containing the primary psychological functions and thus allowing the subject to receive the interpretation, and therefore to accept the change 'as if by magic' (Zucca Alessandrelli, 1998). Following the work in progress at the CART Study Centre in Milan, it is important to reconsider the latency period since it is during this period that the more appropriate defences between instincts and external stimuli are constructed. We therefore regard what contributes to this objective, including GRF, the 'therapeutic latency'. GRF is a new type of answer (that we'd rather call group experience and not therapy) for those cases in which the patient exhibits a pathogenic state and a fragile Self, and therefore where there is a need to reinforce the psychological apparatus, the protective shield. Other cases where the GRF may apply is where there is a more or less serious pathological scenario, yet the first requirement remains to reinforce the protective shield before carrying out a proper psychotherapeutic intervention. All this to allow in both situations the recovery of the basic psychological functions i.e. the recognition of his own Self and the ability to take care of it through the emergence of awareness (Zucca Alessandrelli, 1998). Following this objective of the patient's development we are able to create therapeutic groups such as GRF (with fixed duration and clear aims) and with characteristics of homogeneity. Sizeable portions of patients that we wish to take care of using these group settings are individuals affected by dependence pathology (e.g. drug-addicts, anorexics/bulimics, juvenile depressions). That is to say, that they belong to disorders expressing a psychopathological mould laying in narcissistic problems and in the those of dependence. A dependence on a substitutive object which has grown too important to fill the discontinuity between the Self and the outside and to allow the patient to recognise themselves, due to a sort of hunger and object craving which is essential to the person's life. The object offers experiences based more on a self-referred sensoriality than on a relational exchange, clearly owing to a child experience based on limited introjections and numerous incorporations. The introjective function seems to have been lacking and inhibited by a scarcely delimited Self and therefore by the absence of a proper protective shield, consequently what comes from the outside is believed to be dangerous because too exciting and invasive. In this way the body cannot but become a fundamental element of the self-identity (Zucca Alessandrelli, 1999) The same difficulty to metabolise the affective life and to develop an identity not based on an anguished research of immediate external answers, is found both in juvenile depressive apathy and also in some cases of 'as if' personalities. Thus the excessive need and the object-hunger according to Eveline Kestemberg (1972), seem to be the main factor of these psychopathologies; the crucial origin that the clinicians have to reckon with. More specifically, the object of attention, in our opinion, regards the emotional intensity, the excitement within the relational tension which is driven by this 'hunger'. If the relational tension is conditioned by the need of a self-identity the investment towards the object will be abnormal, since these patients ask much more than a simple exchange. They require the object to become part of an identity that is devoid of individual and personal boundaries. The external object, for these people is not separate and distinct, but rather it acquires the necessary function of protection, recognition and mirroring of self. We share with others (Kestemberg, Lebovici, Diatkine, Jeammet's as main references) the view that when the object is missing, the individual with narcissistic and dependence problems finds himself in a situation of anguish and depletion that force him to eagerly search for substitutes such as alimentary or artificial substances, or dysfunctional behaviours (e.g. compulsive sexuality). In all cases the feeling of Self is reduced to bodily sensations as opposed to emotions. The use of the body becomes necessary to feel vitality and warmth, even though, not infrequently, the ingestion of artificial substances or food is also perceived as a filling of the internal, sensorial bodily world, accompanied by an invasive sensation. And this can oblige the blocking of instinctual needs to avoid the danger of this invasion. It might lead to anorexia, to depressive apathy or, as we have recently seen in a number of cases, to strongly narcissistic retreats where the only possible contact with reality is the virtual world of Internet. So for patients being offered a long term individual therapy (with a single therapist) of which they may both feel the need and at the same time fear the possibility of being overcome by the therapy-therapist object; which therapy is needed? Accepting the hypothesis of an excessive relational excitement, and if this is in fact based on a fragile Self incapable of carrying out its mediatory role between instinctual life and reality, the need of avoiding such excitements seems obvious. The therapeutic group, composed mainly by the so called 'peers', makes more plausible and acceptable a closeness, since peers are less exciting objects, and also less invested of transference. For the same reason the group can have a mediatory function that develops the psychological apparatus. By grading and rationing the excitements it allows the circulation of communication and, therefore the growth of awareness. The peer-group, according to Zucca Alessandrelli, promotes the exchange of energy and evokes the primary pre-object transference. All this restores the function of protective shield, between inside and outside, of the psychological apparatus. Problems of mediation and of fragility of the Self which block the basic psychological functions are found also in patients with either polymorphic symptomatology or with a definite syndromic scenario that are not directly related to an object-dependence (food, substances, etc.). For example patients suffering of panic attacks, phobic or depressive situations, adaptation and somatoformic disorders. However it is important to recognise that the need of the object and the recognition by it is common and also present in so-called normal people. But in which way (avid-arrogant or relational of exchange) and how much do different patients (affected by dependence or psychological dependent) need the saturant functions of the substitute object (substance or figure invested with vital meanings)? If this need is excessive or even perverted then we have to intervene with the instruments of 'therapeutic latency'. GRF, as other therapies, is part of this area of interventions and, as we will see in an upcoming paper by Zucca Alessandrelli, it helps in preparing the patient, through that pre-object transference, which can be viewed as a creator of meanings and environment (understood in the sense used by Winnicot's mother-environment). This transfer of environment and meanings can happen only in the clinically aware presence of the therapist, as during the first stage of the child's autonomy (Winnicot). Winnicot's conception of the first stage of a child's autonomy was defined by the presence, at an adequate distance, of the mother; in the same way this group experience is characterised by the work of the peer group with the presence, at an adequate distance, of the therapist. The GRF, according to our theoretical model, offers a light dinner to people with poor digestion. It can be an experience that, if properly assimilated can lead to the recovery of primary psychological functions and to the activation of preconscious functions. In this way avoiding dangerous excitements that could make us loose the patient. This will allow the more pathogenic individuals to resume their journey by themselves, whilst allowing others to ask for a therapy that will lead them along the path of awareness and change. This objective seems to us, particularly suitable not only for this sort of 'new generation patients' (which seems encouraged also by the society of narcissism and of appearance), but also for the new requirements of the Public Services overly determined by economic reasons. It would be nice to think that the Public Service will take in its charge the minimum but essential objective, of a subject's recovery of psychological functions and thus support in important ways the private analytical therapies. For example the inattentive assessment of patients crowding drug-recovery services can lead to interventions centred on harm-reduction, running the risk of allowing the patient to enter a chronic state. In a similar vein to the psychiatry Services which relying too heavily on drugs or on projective counter-identifications end up achieving little change. So, is it better not to intervene? The best option is of course an adequate intervention. This group technique born from increasing 'field' experiences which are now being published, requires a therapist with good experiences in a group setting since he/she has to be able to define the field of intervention and also avoid expressing the many interpretations being formulated internally. The short and focused nature of the intervention will also make the therapist rather prone to drive and to indicate objectives and models. And this, as we have already seen, can be perceived even more by patients as something artificial. As a matter of fact not infrequently the people involved in group therapy are surprised at the emotional truth of these relationships, in a context (the therapeutic one) which appears so different from those of normal social groups. Artificiality (in the etymological sense of 'artfully done'), according to the Study Centre and its guide's expert opinion is at the same time both true and false, it is both dream and reality. This is even more obvious in a group with a short and determined time span. The atmosphere here created is founded on a preconscious functioning. Through its creative power, it differentiates itself from the 'being attached to something' function i.e. to the object-dependence, and to the dependence on the usual social group (based more upon precise codes). This is the more noble aspect of the 'artfully done'. Relationships have a time limit and perhaps for this very reason, they allow a new prospect without scaring too much those people particularly sensitive to dependence. We can present here a small example of a short-term group experience (GRF) carried out in a psychiatric service, illustrating a case of a patient that we will call Marina. Marina, after this group experience, requested an individual therapy that she is now facing. This patient has already gone through a sizeable part of the therapy exhibiting those behaviours that we might expect from this kind of personality. For example, in the group she was exhibiting all her ambivalence, she was always sitting close to the door, one day she seemed reborn by the previous session, while in the following one she felt disappointed and depreciated, in seesaw of object-idealised attachments and narcissistic disillusions that have always characterised her inner world and her life choices. Results from the Blacky test, administrated before the therapy, suggested that the patient exhibited a severe problem in the area of autonomy from an annihilating mother figure, widely denying the anxiety-inducing Oedipal problem. In her life, the father was only a violent drunkard who soon left the family: Marina was only five years old. After three quarters of the group experience, the patient dreamt to shake hands with the therapist, his finger penetrated into her arm giving her vital energy which she celebrated buying a green hair ribbon, on leaving the session. Even now she wears a green bracelet, she often dresses in this colour and she shakes therapist's hand at the end of each session. You could object what the group had to do with this dual image where the patient makes herself subject to an act of revitalising penetration from the therapist. We think that the short-term group allowed her to bear this encounter and these sessions which the patient is now able and willing to confront. The conflictual transference tension was surely maintained within the group which by discouraging the generational transference was able to enhance the role of the peers. More specifically exploiting those topics connected to the focus, the conductor's principal aim was to reactivate the patients' feeling of Self and their ability to recognise themselves as the main authors of their emotional life. Marina and the others, as we will see from some of their dreams brought into the group, recognise in the here and the now, thanks to the peers' group interaction, also figures of their past, carriers of denied conflicts, as for example the father. When rereading some of Marina's Blacky's tables administered at the end of the therapy, she seems to have gained access to the triangular dimension and rediscovered the presence of the father. Some of these suggest she has perceived the possibility of separation, although now Oedipus and its potential anxiety inducing vitality are emerging. But it is still the primitive and castrating Oedipus that dominates the tables' answers. For this reason the patient lives dramatically the moment when, at the end of the group, she feels the possibility either of a void that cannot be filled or of a therapy to try, this time, to carry on that deep change that wasn't the GRF's initial aim. The patient is now following an individual therapy and she seems to be on her way to facing the difficult, but challenging path towards awareness. Not infrequently an important result of GRF is to make possible the real asking for psychotherapy. In conclusion the Group for the Recovery of Functions wants to be a new therapeutic resource available to operators, with its specificity. Specificity which consists not only of a group setting as a scenario that generates symbols i.e. a place where it is possible to conceive of what was until then inconceivable but also of limited time, of generational transference investments on therapist, of positive prospective and constructive tension of the peer group. So, GRF as a different answer, that is able to surprise, that has as a main aim to re-ignite the psychological engine of the patient, and especially allowing the patient to rediscover that the energies for change are within him. BIBLIOGRAFIA:
1) S. Lebovici, R. Diatkine, E. Kestemberg."La Psichiatrie de l' enfant" . |
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