“What story down there is awaiting an end?” Group work as a therapeutic function.

Sara Molgora, Emanuela Saita, Valentina Fenaroli

Abstract


We have been working for years at a Mental Health Service operating in a neighborhood of Florence. This service has been organised over the years in well-known points of the city that are in constant transformation and that now after years of work have become a part of our emotional and imaginative baggage. They have also taken on the sense of “mental places”, like those experienced in dreams or acted out as memories, located half-way between natural and cultural systems and triggering a process of individual and collective sedimentation in a society that leaves its trail on the ground. The space one lives in is one of the foundations of one’s personal identity, and the home, just like the Mental Health Center, is the privileged place in our daily life organised around time, where there is order, certainty, stability and continuity. In short, the consulting room/home is a place for storing memories and experiences. Inhabiting, according to C. Norberg-Schulz (1979, p.34): “…means experiencing life as a multitude of possibilities. The sense of identification of one’s home can be so profound that it is felt to be the symbolic extension of one’s body, and likewise the home with its confines establish the distinction between self and others”. These are identity confines which each person needs to construct for himself, but that can become a trap tying the individual down to an life-story set in stone. Abraham Moles (1971), a social psychologist, identified a space perception set, which he calls “man’s shells”: the first is the body, or what is divided off by the skin; the second is the gesture, the space of movement; the third is sight, the room; the fourth is the dwelling, the private space; the fifth is the neighborhood, representing meeting others.
 
Our service, in the place/neighborhood, has been organised over the years both as psychiatry for the local area and for the sheltered community. Local area psychiatry, which tries to contribute to the mental health of a community, features certain organisational and methodological strategies: a network of services and protections that are not just coordinated but almost integrated; a moderate “scientific” use of psychopharmaceuticals; integrated techniques in increasingly complex programmes; the valorization of personal relations with attention to the issues underlying symptoms; an expansion of the possibilities for psychotherapy; the use of intermediate facilities for treatment; the use of the normal resources of the local area for purposes of therapy. 
Mental health community psychiatry introduces another element of knowledge and above all for therapy: group work. This ambiguous and purposely vague term can mean both the tendency to report to the group whatever the single staff-member feels and experiences, and a way of working in the treatment facility where the mental aspect recognises and constructs a space in a complex multifaceted area (Fasolo, 1994).

In such a kaleidescopic field, talking about treatment in the official Facilities from a psychoanalytical perspective leads us to wonder how this can help to understand the facility, amidst the complexity of individual, group, organisational and management dynamics, interwoven on many levels, both real and imaginary. In the still common paradigm marking the psychoanalytical contract, the individual, private roots act as a defensive barrier against the “endless critical and emotional work that forms a whole series ranging from the individual intrapsychic dimension to the social and collective interpersonal sphere” (Petrella, 1981, p.500). It is this experience of the “plural” (Kaes, 1993) that distinguishes the Facility as a therapeutic workshop, capable of taking in new objects of study and treatment: the group, the family, and in particular, pathologies classed as “serious” that are often inaccessible for the tools used in the classical setting. The “plural” experience, part of the complexity of the institutional field, is supported by presence of two tendencies: one vibrant; the other violent and deathly, in a strictly codified reciprocal presentation involving a sort of compulsion to repeat. This experience is common to all the Mental Health Centers.

Group work in our experience is the way our service operates, offering the patient and staff the chance to experience diversities, constructing group psychic spaces, where shared experiences can be symbolically re-elaborated. Group work can therefore be seen as the transformational role of the Facility. 
Increasingly in sheltered community psychiatric services, there is the need to construct conceptual tools to define and assess the group and institutional factors that work, change and are concealed in everyday therapeutic practice. The definition of this set of tools finds a very strong stimulus in the way the public health organisation has been rapidly and often wildly turned into a business. This has radically changed the institutional field and the dynamics it involved and therefore the traditional concepts of psychodynamic knowledge, of psychological reading of the individual, group, or community dimension must be constantly subjected to criticism to avoid taking a “finger for the moon”.

We are going through a period where the “business” aspect of the mental health services has led the idea of organisation to lose meaning and to be interpreted as the attempt to control or hide the individual nature of the staff-member exposed to serious pathologies and where phenomena of transferance take on a special loaded sense in the individual-group-facility sphere. As Arrigoni Scortecci (2003) succinctly puts it, the use made of the organisation is often avoidant and phobic, to escape from the anxiety of the individual responsibility of accepting a profound dependency, without making a distorted narcissistic use of it. 
The “famous” business transformation has revealed more and more not only its institutional constraints, but also the set of procedures that the services feel to be a persecution: cramped spaces, precarious funding, forms to be filled, and the information system. Unlistened to demands are made, where there is a “syncretic” (Bleger, 1992) fossilization of outdated individual or group aspects, both building up an amorphous parasitic area that tends to perpetuate the organisational aspects most resistant to change, and amplifying the original disruptive demands (envy, exaggerated conflictuality, manipulation, etc) which convey impotence and “paranoia”: this is how any collaboration in the functioning of the mental health services is attacked and undermined.
In this climate of team work, as described by Marta Vigorelli (1994), there is not only a mental state to coordinate, but an actual organism to keep alive. So the tired futile contrast between organisation and culture in the carer groups is overcome in a global synthesis of the operation of an institutional group. This is true also for the therapeutic community, “the Care Home”, whose therapeutic and iatrogenic factors are linked both to the individual mind and to the group dimension, to the time passing, to the continuity and cohesiveness, to the crisis and breakdown of sense of self and its relationship with the universe of family and social meanings. In the services, dealing with this contradictory aspect allows us to understand why a patient with psychotic borderline traits needs a community not in the generic sense, or why in the chronicity of self-representation of the divided self, it is the only area of shelter and a place where the patient feels he can live.

Some words, bridges between differing knowledges, are always with us when we think about these issues. 
Institution: describes anybody, formed in the past, of social grouping with overall aims concerning the existence of individuals. In a psychodynamic perspective, it is conceived as the outcome of the process of collectively constructing and sharing symbolic relational models.

Field: a concept generally understood as “collection of strong fantasies, emotions and shared images”, undergoing constant evolution and transformation. An example is the concept of field applied to institutional psychiatric groups working in the local area, which Antonello Correlale sees as deriving from his personal reading of K.Lewin’s field theory. He is therefore moving parallel, though with different original nuances, to other authors, both Italian (Corrao, Neri, Barnà) and foreign (Willy and Madeleine Baranger, Bleger, Jacques, Kaes, Anzieu), who have referred to the same concept during their psychoanalytical reflections both at the individual and the group level. For Correale the field is therefore “the overall set of mental factors working in the group, with its specific connotations of emotion, climate and atmosphere”. And again: “An area of phantasms, ideas and shared experiences, a scenario, a narration and not a role play” (1991, p.43). With reference to the treatment of serious patients, there arises a shared field where the plurality of the figures on the one hand makes it possible to dilute and differentiate the marked affective investments, while on the other hand it may enable internal dynamics to be acted out and focal points of suffering to be understood. 
Working group: “ …not only a sum total of roles and functions, but also like an actual group field of experience, affects and shared representations, endowed with its own history, its affectivised memory and its shared project-making capacity” (1993, p.143). 
In this article we look at the institutional group, showing its role in the care of serious patients, referring to the basic therapeutic factors which are, according to Correale always present in the group as such, independently of its specific type. These are therapeutic factors that, while having different modes of expression, affect the common good, namely the sense of cohesion and continuity of the self, so seriously threatened in the majority of psychiatric disorders.


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Rivista di Psicologia Clinica. Teoria e metodi dell'intervento

Rivista Telematica a Carattere Scientifico Registrazione presso il Tribunale civile di Roma (n.149/2006 del 17/03/2006)

ISSN 1828-9363

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