These words written by Freud are a suitable introduction to my reflections on group therapy for patients affected with Crohn's disease. It brings about an opening in the emotional and logical complexity of describing what happens in a group whose task, which is "declared openly", is to help the patients to accept the serious and chronic organic pathology as Crohn's disease. I have used the term "declared openly" as its meaning more or less underlines the initial qualities of cognitive rigidity, exclusion of any carrier of disturbing emotions from the conscience field, necessity of strictly following the medical requirements and denial of any confusion brought about by this confrontation with Crohn's disease both in the staff and patients.
I shall try to trace the various cognitive courses activated by group experience aimed at building up knowledge, the result of imaginative elaboration of the elements of reality which transforms a number of isolated ill patients into a "ill group" with the task of facing and confronting the pathology of the bowel which bear this disease.
I shall underline that the initial knowledge of Crohn's disease, declared and accepted as demanding only improved compliance with therapy, is a defensive and occlusive instrument compared with knowledge understood as a harmonic emotional-logical process of the disease.
I shall analyse the quality of the request and the organization of the cognitive course through an intersubjective continuum that has spread from a little group of patients to a staff group and to the institution in as much as the group widened producing cognitive elements organisable poles in a person's mind to gather and hold proteiform reality of Crohn's disease.

The experience.

The group was held at Faculty of Medicine as a further amplification of a programme of collaboration between the Psychiatric Department Psychotherapy Section and Gastroenterology Department.
The work of the team (psychotherapist-gastroenterologist) has been active for more years than the diagnosis and communication with patients suffering chronic inflammatory bowel diseases as CUC or Crohn's disease.
Within this therapeutic alliance and in the reflection of the difficulty in the management of patients with Crohn's disease is the motivation to give them psychological support.
The pre-group foundation is based on the request for an improvement in compliance to steroid and Asacol therapy of patients affected with Crohn. Gastroenterologists have been motivated to make this request on bases of their observation: the patient's resistance in accepting that the disease is chronic, refusal to undergo colonoscopy and small bowel enema for evaluating the progress of the disease, impossibility to follow a correct diet to avoid further inflammation of bowel wall, the "strange" forgetfulness of drugs which are absolutely necessary for them.
The element that has come to my attention, after a careful study of the disease, is the perception of aspects which are not communicated between the gastroenterologist and the patient. The latter, who is the protagonist, seem to have a knowledge of Crohn and a personal experience of aggression and refusal to accept the diseased bowel, signs of a very serious feelings, while the hospital staff seem to put it together on the same level as any other chronic inflammatory disease in respect to survival, the quality of life and the stabilization of the symptoms and attaching the unforeseen seriousness to the insufficient patient's will to follow medical treatment. The back-ground of the request opened on an abnormal gap in which the group experience was seen, above all by the hospital staff, as an attempt to construct a union between patients and doctors an at the same time as an informative and educational experience for the patients -naughty and irresponsible children.
The request, in its clear form, was marked by a lot of comprehension and a lively concern to give support to the patients in fighting a serious and, sometimes, disabling pathology that needs also surgery on stenotic bowel or fistula. The request is reinforced by the suspect that in Crohn's disease, even though there is a certainty of heredity and immunity factors, there is a psychic factor that in some way interferes with the course of the illness. So, the frustration of the doctors colludes with the patients' in motivating the necessity of a psychotherapy help that is charged to provide adequate answers and reassurance that doctor is good at reinstating good health and also the patient's need of not being condemned to a precarious quality of life risking permanent infirmity which dictate their behaviours and relationships with others.
It is quite difficult to examine all the various aspects and trying to construct some order that, despite the experience seems to trascend in a chaotic way, I shall try to construct, in an artificial manner, a selection of the various elements, then to attempt to propose a possible integration. The process corresponds with the level of concept to the of knowledge that, through the various elements of the experience, has allowed the patients, gastroenterologists, and psychotherapist to regain and elaborate in an autonomous form the object, the illness, and the subject, the patient.

The group of patients

The clinical complexity, the arising of pathology in other organs and apparatus (articulation, bones, skin….), the strong abdominal pain and diarrhoea mark the life of patient who feels pulled into a tunnel of physical suffering, the fear of this, the agony that lesions may become neoplastic.
The group, in the initial stage as a meeting of ill individuals, begins and looks at the loss of hope, while the subject is continually stimulated by gastroenterologists to become an active part of the therapeutic process by collaborating, paying attention to the therapy, standing up to physical pain. The patient accepts to take part in the group wanting to regain hope and needing to share the project of rebirth thanks to a third person, the therapist, who is neither a doctor nor a patient, both from the illusory strivings and grief which has filled him.
It can be affirmed, from the first session, that one comes into contact with a sort of group illusion understood, as Neri says, as corresponding to a desire of security, of preservation of the threatened "Ego" unity. So, the illusion is the foundation of the group and represents a "necessary idea", a pulling and involving idea. Other than this the group becomes a place for depositing their not changing identity aspects in order that the patient-group can begin to work on facing the storming generated by the events which follow, seen as Self destroyers, elements of attack on their identity. The therapist's work, using the group instrument, helps to facilitate a field structure such as a mental state, that is "a complex of fantasies, emotions and ideas joined to each other" that can exist outside limitations of space and time.
In groups of patients with organic pathology the therapist's work, if it has the object of building up a knowledge relationship with the ill body, must reinforce the actual field in order to reach that place that, as Correale says, is "the result of bringing together images, thoughts, meanings, but also affections, impulses, emotions and sensations present and active at a given moment". In my experience, during the first group session, one worked on the possibility of each group member of exiting from the space of their Crohn to accept the confrontation with that of the other, felt as not other by Self, but as an expression of belongings aimed at organising a knowledge of the disease and an instrument for facing up to it. The difficulty met in this first phase was tied to some fears of patients affected by not severe Crohn with diarrhoea, anaemia and lack of appetite to look at the members with a grave form with stenosis and fistula, waiting or already undergone surgery, while this latter felt pain and a sense of exclusion in regard to the less ill members. They became a mirror each other and at the same time represented a resistance in taking hold of the possibility of a cure. All the members share the desire of forgetting the disease, denying fear and physical pain. It became necessary to elaborate a possible integration of the various aspects amplifying narration by asking each member to tell their own experience from the point of view of reality end emotions felt. The technique of commuting has consented the patients to recognise the communal points not tied to reality but to the psychic. Even though there were many different symptoms, the members of the group discovered, thanks to the association, a feeling of unity; joined in the same fantasies of loss, attack, the same feelings and dreams of healing. Each one could confide his own fears and hopes with someone else. Through this technique has begun to construct Crohn's disease, coming out of the isolated position of their own individual disease to be able to relate well with the medical group.
The alliance between group members, maintained by the leader, has allowed the emotions about the medical staff to emerge. Some members have understood that is possible to connect their own frustration to the "incomprehensible" message of the gastroenterologist. "Incomprehensible" because, despite the apparent security of therapies, the possible evolution was not clearly described to them. So, the Crohn's group has had the courage to unveil the gastroenterologist's motivation to the group. The singling out of the doctor's impotent aspects (they did not have efficient therapy), the refusal to participate with pain (a colonoscopy must be carried out a lot of fuss) has activated emotions of aggression (the doctors are not human beings, they treat us like objects) and has got rid of their sense of guilty for not following medical advices. The group has allowed the gastroenterologist's emotions to emerge: anger for not having a clear answer has been embodied as well as the pain of knowing, before the patient, that he has begun a walk of physical sufferings, sometimes strongly infirming. This process has led to an enlargement of the group field with the doctors becoming part of the group. Gastroenterologist is recognised as the producer of the same fantasies and, at the same time, as the person who has the power to follow up the dreams of healing entrusted to them. The leader is seen as the organiser of the mind-body integration process and as a bailee of their newly acquired knowledge. The disease begins to become something that belongs to members with which to have a relationship and confrontation and it is transformed into the "bowel ill" that has to be looked after and protected by the group-mother, developing a sort of maternal holding bringing about more attention to keep to the diet and a better memory for taking drugs all the time. The establishment of the emotional field allows mental pain to be put together with physical pain as a space to put agony for future, a powerless sense of not being able to control the future of illness, anger at becoming dependant on their own family, drugs and doctors, grief for the loss of autonomy expressed as incapacity to be a protagonist for their own choices and projects for their future.
At this point of the experience, the fermenting initial elements begin to be organised, but the confusion caused by the unsure clinical course motivates research for another place of containment. The group consider the possibility of efficient therapy to arrest the slow course of the disease definitively. The need of hope, the part of dream (desire for healing) is moved outside the group in its space and time to the enlarged group of the university institution that receives the group and of which patients, doctors and leader feel to be part. As the University is a place of research, it represents a space to set the hope: the possibility of contact comes about by weaving together the group members with the staff of Psychotherapy unit, the nurses on the gastroenterologic ward. The passage can be observed by the presence of more members, as single individuals on which each can entrust emotions to members as part of a whole with specific functions. The group has gained the knowledge of being able to transform dependence into inter-dependence, that is to form relationship at different levels that can be recognised as belonging to the original group. This process is underlined by inscription of members in the Association for Crohn Disease Patients, an association of patients aiming to promote all initiatives of helping the patients.

Conclusion
The description of this experience underlines some aspects that can be considered common to the therapeutic groups of patients with chronic organic pathology. It seems that putting affection in the right course, supporting during the crises, defending from the disease and acquiring the courage to remain a person can be considered as the objects of this type of group.
The field that takes shape is a space between supporting function and reinforcing Self process. It requires the use of complex modalities where necessity prevails to enlarge the borders of the group to re-discover continual belongings. This movement makes us think about the importance of the course of emotions in the belongings group. We have seen that the phenomenon of trans-temporal diffusion permits, beginning from a patient group and going to an institutional group, to build a larger place: the "patients-doctors-institution group" that corresponds to the need of acquiring new strength and new elements to contain that which is lived as a proteiform entity and difficult to control. Therefore, three fields, apparently different, "are found to have more common elements and are assimilated" (Neri). Because this process can take place in its meaning of stable setting and not as acting of the confusion levels, the leader should propose a way in which the group can stabilize the initial reasons. Setting elements acquire a structural importance not only in defining the space, place where it is possible to meet and deposit experiences, but in representing the nucleus to recognise oneself as individual with an illness. The objects employed can be singled out word that is the strong way producing exchange among members and the physical disposition of the group that stimulates the use of elements of non-verbal communication.
The word, in its aspect of a known instrument in a meeting, is used at the beginning of the group as an underlining for individual spaces and in sharing parts of the Self. There is an inconscious defensive use of outlining ones own world, of hiding ones own emotions that the group members do not feel like sharing. The group, when use an inconscious instrument, allow itself to activate "functions and representations, disphoric moods, way of relating to their internal objects" (Kaes). The attention to body sensation activated by posture and physical contact can be found in word that becomes expression of the inconscious wish that is "meaning able to construct sense, decoded, translated, explained"(Kaes). Therefore, the work on body aspects as meaning of communications among members of the group is the course that brings to the transformation of the word from defensive object to expressive object. The group is begun with words, with sentences and thoughts which, trough the commuting, allowed to tell about oneself without feeling themselves discovered, not noticing the lack of the individual element that every member recognised: my way of living physical and mental pain. In the first session, the patients, entered in the group room, were amazed not finding chairs. Everyone tried to relate to one other, standing up, looking for a place by a physical closeness. The members, in their own physical disposal, pointed out the aspects of loneliness and confusion. The leader invited them to seat down, forming a circle and to listen the rules of the common work. The activation of setting device in defining the place and the space, had formed a bank of the elements of confusion and activated new communicational possibility. The time session, the day and the length limit, in a reassuring way, a range of exclusive belongings; the physical way: the circle manner, the touch of hands keeping a period of silence, initial ceremonial of every session, build a different possibility to recognise the other and the body that was kept until then as excluding element because responsible of pain. During the commuting some temporary modifications were brought in the circle arrangement to permit the acknowledge of the communication difficulties. The technique of commuting looking straight in the eye, one in front of other, or turning one's back to other, corresponded to the moments when the group needed to set apart or fraternize trying to become subject.
In conclusion, the leader allowing the development of cognitive course, must analyse the meaning of the elements (patients, gatroenterologist, psychotherapist, university) and recognise the structure elements of the new bond that is forming. This movement can be consider as a process of Self reorganization.
The patient's group can be recognized as Alter-Ego Self object who, as Neri says, supplies a "continuous presence … it gives an essential share to the building of the feeling of human being", in the process of strenghthening of Self necessary to support the disease's experience. In this process, as Trentini says, "the group represents for the individual an important source of confidence an certainty capable of satisfying any subjective anxiety". The group as Self object can allow himself to make a projection of the idealized Self object onto the group gastroenterologist-university, recognized as part of the Self. So, the latter can be recognized as ideal-Self object that, as Kohut says, is fundamental if it allows transferring the primitive omnipotent Self on the idealized object. All that is functional to reinforce of the Self if it does not require a separation between subject (patients' group) and idealized object (gastroenterologist-university group). Enjoying that, the group ideal Self object place a part of shared omnipotence at group's disposal.
It is possible to say that in the leadership of groups with patients affected by organic pathology the leader flexibility, his cleverness to pick up the meaning of every elements and that of using them again to reinforce the Self, activate and build the process of knowledge of the disease. Thus, the group's members can learn to live together with the chronic aspects of Crohn

.