The fourth element a way about clinical groups

by Alfredo Anania

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INDEX
1. Introduction
2. Survival systems
3. The quaternary element
4. Group-analysis
5. Group by the music
6. Large group
7. Group for pregnant women
8. Experiential group training
9. Group for insulin-treated diabetics
10. Psycho-anthrop-analytic group
11. The work-group
12. Beyond the circle

1. Introduction
The individual-group dynamics have many implications with regard to the professional practice and frequently they have spurred in myself the query if I were, in my heart of hearts, more inclined toward the individuality or rather toward the "group-world".
This doubt can appear opportune when we consider that an individual who has reached a good internal integration has various possibilities to animate the personal "social Self". Probably it will be necessary an increase of the scientific research on these aspects of the dynamic psychology. By this reason now I make the following ask: what would it happen if from a symphonic piece we separate the musical execution concerning every component the orchestra? We would have some musical sounds but not the execution a music composition. It would miss that connection among phonic events constituting in their whole exactly a symphonic music. Besides we can ask us: what comprehension could we have about the Impressionism if of this artistic movement we knew only for instance a painting by Monet? What is the contribution that Impressionism gave to the Monet's creations? Is a group correlated to a single member as the Impressionism is correlated to Monet? It is possible really to mention the individual without considering his group-dimension? Besides, it is not still resolved the problem if the human tendency to create couples is more associable to the individualistic dimension - because the couple appears excluding the plurality (more tenacious it is the union between the two individuals the couple more tends to isolate itself from the others) - or if the couple represent a transitional and preliminary condition for a participation to the ampler multi-personal world.
It is sure that the third element, the minimum group, the triad originates and develops by a dyad, that is two individuals of opposite sex, on the almighty fantasy and aristocrat that from the couple a new messiah (W. R. Bion) will have origin.

2. Survival systems
If we refer to the biological systems (considering expressly the recent acquisitions about the psychosomatic medicine), undoubtedly we discover a sort of strange dichotomy among reproductive functions, that assure a realization to the species survival program (by the individual survival), and biological systems maintaining the affective binds that we have to consider key for the realization of survival programs regarding either the couple or the group. In fact, we discover in order to the survival that the group and the couple both have their basis on a same biological system that is different from the system implicated in the reproductive program. This reproductive programs that, at least in the multi-cellular life forms endowed with gametes, utilizes the coupling to guarantee that two living creatures belonging to the opposite sex can reproduce themselves and consequently be passed down from generation to generation.

3. The quaternary element
We have designated the triad as plausible minimum group. But is it true then?
By a geometric metaphor we experience some series difficulty to conceive a circle situated into a triangle; it is decidedly warned something incomplete and unbalanced: it recalls the dizziness of the precariousness and the absence, because it misses the balance. In fact, it is unusual and it appears difficult to imagine a central position inside one triangular configuration; contrarily to what happens when it is a quadrangle or a circle. It is just in the core of the circle, in a group situation, that we can imagine the source of the supra-individual mind (W. R. Bion) or the focus by which it emerges a phantasmal presence in the shape of maternal imago as illusory body holding joining the individuals as real limbs of the group (F. Fornari).
From the psychological point of view the mother, the father and the child, the trinity, the third included, brings us to the oedipal dimension, and to the way for the sourcing of feelings as the envy, the jealousy, the desire, the possession, the ambivalence and the emotional conflict develop by the secondary process (S. Freud) rather than by the primary process (as it has been interpreted by M. Klein).
The family triangle is lacking in the fundamental experience of the brotherly presence; it is devoid at least of a brother or a sister. Only so, by the presence of the quaternary element, it is possible to overcome the narrow oedipal microcosm and to arrive at the complete tetragonal family-matrix and, from there, to project toward a polyhedral world and multi-vertex, rich of unforeseen events and of enigmas (the Sphinx metaphorically evoked by W. R. Bion for the group) inexhaustible font of new thought and powerfully myth-producing.
Therefore recapitulating: the individual represents the primary element; the secondary element is the couple; the third element is three-polar and classically it is represented by the oedipal triangle; the fourth element is the tetragonal and multi-vertex group dimension in its circularity.
The Analytical Psychology (C. G. Jung) have repeatedly underlined the tall spiritual value of the mandala, the elevated sense connected to the alchemic strain toward the squaring of the circle and besides the deep meaning - in the dreams, in the collective unconscious, in the art and in the architecture - of every expression that symbolically sends again to the circle and to the squaring of the circle or to the Uroboro, therefore to the archetype of the Self.
Today numerous group-analytical studies (F. Di Maria, G. Lavanco, G. Lo Verso, R. Menarini, C. Pontalti) and various experiences as, for instance, the Itinerant Seminar on "The Symbolic Imaginary" - that it is a group full-immersion in the soul and in the matrix (A. Anania) - contribute to direct our attention not only toward the individual Self but, in penetrating way, also toward the collective Self and toward its relational and cultural matrix, that I have defined as Historical Self.
However by all the studies on the folkloric creations - rites, myths, fables, stories and popular traditions - (M. L. Von Franz; V. J. Propp), on the transpersonal (F. Di Maria, G. Lo Verso), on the Psychology of the Self (O. Kernberg, H. Kouht) and on the intersubjective perspective (R. D. Stolorow), it is unanimously underlined that the birth and the development of the Self cannot happen without the Other and cannot exist without the intersubjective and transpersonal world.
Therefore we have admit that what we call the first element or the individuality, has origin only from the fourth element, that is from the group, passing through the preliminary assumptions: first by the couple, secondarily by the trinitarian dimension or minimal elementary group.

4. Group-analysis
Do I incline more for the individual psychotherapy or do I have a greater propensity toward the group-work?
Probably my scientific and application approach to the group-analysis, has subsequently strengthened in me the natural propensity toward the groups and it has helped me to mature, in the clinical activity, a conduction method perhaps more proper for the therapeutic needs of the patients rather than centred on the self-exploration exigencies typical of the experiential-group and I however warn still today the charm of it that is since from the start of my bionian group-training.
In a previous work, I have underlined that it is possible to observe the group, with regard to its intrinsic complexity and polyhedral configuration, under various interpretative perspectives: "evidently these only are as helpful landmark, models or theories that order the same process of observation (theoretical criterions useful to confer sense and to conceive, in the most disciplined possible way, a lived reality that it is not abstract). Without these perspectives and interpretative models the automatic selection of total reality would to be precluded; the absence of models would come across the experience of chaos or the confusion (in group it is easy the confusion with the same observed object). Insofar we have to accept, that every interpretation relatively to the group constitutes a restrictive but necessary process of transformation of the reality.
The adoption and the choice of perspectives and models by the group-conductor are partially conscious and voluntary, for the rest they are unconscious because they originate from the personal disposition and from life-experience (above all a prominent value has the psychological training).
My mind goes to the psychotherapeutic group formed by chronic psychiatric patients, about them I have already written in "The anxiety of the group". I remember the insistence of the participants in carrying the plastic bag containing medicines and prescriptions, probably because they had the need to sustain themselves on a basic-assumption psychiatrist-dependent and to remain anchored therefore to a dimension, for so to say, "known and familiar"; besides the bag probably was a metaphor in relation to their silent appeal to be "cured" also in a group context.
The group was by me conducted on the experiential model probably because being formed exclusively by psychiatric chronic patients, I unconsciously was feeling it as enough hard and therefore I was inclined to preserve me from my unconscious worry to not be excessively involved in the serious personal problems that the participants presented. I would not like however that how much now I affirm can induce the reader to believe my conduction cold and detached in a way to favour the regression in the patients and to leave free in all their entity the basic-assumptions (Bion). Considering the chronic phase of illness (several patients was frankly autistic) and taking into account the difficulties of elaboration also because their cultural level not was elevated, probably it was useful to maintain the attention more directed on the group in its whole rather than a conduction principally oriented on the personal sufferings introduced by every patient. To this finality it was positive to limit my interpretative interventions and to resort more frequently to the metaphors, to the discursive plots, to the link-weavings among the various arguments that were begun by the patients, above all when their communications appeared notably unconnected the one from the others. Probably, only in this way was possible to this group to live for almost two years.
A group-conduction mainly oriented on the group-analytic model could not evidently happen without one time course and without to go through a transitional phase rich in new experiences.
Probably I have found this infra-space by the conduction of some group-therapeutic activities, reserved to patients hospitalised in a psychiatric service, the reunions were twice the week through two different settings.

5. Group by the music
The first one was a "Group by the music" - that it substantially differed from a group of "music-therapy" because it is not a treatment through the music but instead a group-discussion that starts the communication from the preliminary listening of a musical passage that is spontaneously picked out by someone of the participants. Initially I thought opportune to put to disposal of patients various cassettes reproducing both classical music and songs; but, with the progress of the experience, I understood that the sung passages (both lyric musical passages and light music) produce in the patient much emotional tension because frequently the contents of the songs is able to provoke in this or in that patient (it is not necessary to underline that generally they was acute or revolving door cases) the return to deepest personal removed worries, from which the patients tend to shelter themselves or tend to check by the pharmacological therapy. The contents of songs, as known, generally propose some life-themes rich of feeling and passion: the loneliness, the loss, the incomprehension, the disappointment, the love, and the jealousy. Instead, the symphonic music appears deeply cathartic, joining and pacifying. I felt that the patients were participating, with "religious" listening, to the "universality" of the music that, in combination with the group context, opened a "numinous" space particularly appropriate to the imaginative production, to the free-associating, to the "interpretative" communication.
The other weekly reunion happened as a normal "clinical group", by me conduced employing the traditional therapeutic "setting".
The insertion of the group-psychotherapeutic among other routine activities in the hospital psychiatric service, has allowed me to verify the potentiality, underlined by numerous authors, relatively to the therapeutic "group-setting, as efficient "holder" relatively to the most explosive psychopathological emergences and as "tool" useful to relieve the deep isolation-sense of psychotic patients in need of elevated assistance; besides, as precious tool to favour the communication, also through the increased opportunities for every patient to be mirrored each other.
I cannot forget the case of a strongly aggressive "giant" participating in the above-mentioned group as external patient. This person, in the past repeatedly hospitalised and able to smash with his punch the body of a car, one day he came to the group-session after to have watched a television-film that was the story of a man whose uncontrolled "escalation" of violent actions was stopped only after the capture by the police. My patient told to be shaken by the vision of the film and now he was convinced of the necessity to put end to his outbursts of anger and to abandon, as he said in the course of that session, the "almighty sensation to be able to give scot-free to the own aggressiveness. From then, really, he finished his violent behaviours and it doesn't result me that later he was author of new aggressions. Rather than the subject of the mentioned film, I believe, the substantial turn in the behaviour of the patient has been caused by the participation to the psychotherapy sessions and by the occasion to confess to a "public co-elaborating" the internal solicitations toward the dangerous behaviours of which he was protagonist and in comparison to which, rather than with the fear or with the refusal, the group had reacted with an "holding" behaviour, more offering him an "emotional eco" and functioning on it as "detonation box".
Useless to underline that music listen characterizing the first part of one of two weekly group sessions and called "Group by the music", it was useful to activate the communications among the participants but, because the music pertains to so much the body how much the mind, it is also a meaningful space both to unite and to elaborate the emotional feelings and to warn the movements of the Soul transmitting her metaphors with advantage of those cathartic dimensions connected to the self-narration out the ordinary world; as it is without time the maternal lullaby, despite it has accompanied a period of our existence that is datable only with an approximation.
To graft a something new inside an institution or a cultural context or a territory, it is not an easy operation and it makes to live all the difficulties alike that every pioneer has experienced. In the institutions, the roles playing and the mechanisms of power it is true they can often hinder the most innovative realizations, in particular when they are initiatives driven by workers occupying positions "hierarchically" subordinated, but other times it is possible to verify the opposite case that is the realizations come only by the personal will of who is to the apex of the responsibilities. This is my story, so citing my experience, despite the invitation more times turned toward many collaborators to start group works, I remained for a long time, in my department, the only operator conducting group-psychotherapeutic activity.
The small group knows the disillusion in the larger group.

6. Large group
With the purpose to spread the familiarity about the groups and to involve the entire staff in the group therapeutic activity, I started a "large group" formed by all the people that were for the moment in the department: hospitalised persons and coincidentally them relatives, patient in day-hospital and naturally the entire staff including the nurses and the assistants.
This setting facilitates the collective involvement, therefore the expansion of the communication level and the intensification of the "network" besides, paradoxically, a greater intimacy at level of the subgroups. The disadvantages in comparison to the small therapeutic group, by my opinion, are perceptible above all on the psychodynamic plain because the large group can intensify in the participants the unconscious worry of fragmentation, regression and individual loss of identity; reason why above all defensive projective processes are mobilized, in more archaic and thick form. But more the collective worries raise about the chaos and the confusion so more the single ones are solicited toward the unconscious activation of some psychic functions that allows the logical reorganization and toward some emotional processes that contribute to consolidate the affective attachment bind. In my experience, the large group is above all characterized by the number of speeches finalised to rationalize the collective experience, by the wealth of communications in the form of "metaphors" and of "parables" regarding the personal life, at least by the tendency to multiply the "intimate" subgroups.
In a precedent work I signed that it is possible to see generally in every group, but perhaps in form more evident in the experiential group and in the large group, the presence of the so-called "collective illusory phenomena" or of "psychotic behavioural models" or of "typical dream-elements (absence of negation, a part for the whole and vice versa, condensation, absence of space-storm order, censorship).
Since every individual participates in the group to the purpose to be able to work better as integrated and interactive person, seeing that the group determines depersonalisation and dreamlike phenomena, the speeches of every participant can be read as an effort to resolve the dreamlike flowing in the group, or better as the final consequence of two opposite movements that is between the tendency of the dreamlike to emerge and the contemporary necessity to check it to maintain an adherent way to the reality principle.

7. Group for pregnant women
The dreamlike, as perhaps it is natural, emerged in all its sovereignty, in the good and in the evil, in the "Group for pregnant women" by me conducted in general hospital for about one year and that remains, as it regards me, an exceptional experience on which I will want to return as soon it will be possible
The pregnancy is a natural event, but in the imaginary collective it maintain some magic value. The dreams of the pregnant women underline the ambivalent feelings that accompany the pregnancy: the waiting, the hope, the love, the devotion, the sense of completeness, the procreativity, but also the limitation of liberty, the physical transformation, the discomforts, the worry about the possible damaging the little being in the womb, the anxiety for the birth, the pains and the fear not to give the child to the light or that he won't be born healthy and the fear that he can bring the death to his mother.
The physically enlarged body hides the delicate, sometimes fragile, psychological dimension of a woman in "interesting" condition: the kaleidoscopic to variegate of the day-dreams is accompanied to a continuous need of external support, for which the transpersonal dimension plays a notable role both at the ethnic-anthropological level (and archetypical) that at the "trans-familiar" level. The attitudes of her husband and of her mother have a fundamental role.
Has impressed me the deep need to exchange the experiences lived by the women participant to the group in a different context from the banal ordinary thinking and the customary communications that surround the "expectants" and, besides, their great need, despite the pride for "empty" womb, to psychologically be tiled in their gravid going. Probably it was by them primarily important to traverse the period of the pregnancy accompanied by a "good" "combined object" rather than by the alone "good" mother". It can be true that, in my experience, the maternal-female element was symbolically represented by the group in its entirety, while the fatherly-masculine element, reverberating routinely in the figure of the husband, was symbolically represented by me as "conductor".

8. Experiential group training
The possibility to experiment as "to stay alone in presence of the mother", could be an extremely synthetic metaphor for the Experiential group training by me conducted for about three years and reserved to university students of a school of specialization in psychiatry; this training work has again approached me to the bionian conduction model.
Despite some more or less indirect therapeutic needs periodically emerged among the students, I have thought essential to avoid the toning from a experiencing itself group to a psychotherapeutic group. As it is comprehensible it is necessary to avoid both to transgress in comparison to the model and to put together in a same group, to purpose therapeutic, people that are daily together for other reasons. The difficulty relative to conduct a group whose members belong all to the same institution would be become insurmountable by the transformation from an experiential in a therapeutic group setting. In this case the dark wings of the perversion would have altered the unanimously recognized atypical context characterizing this training group and the "good" mother would have been submerged by the intrusion of the "narcissistic mother".
For many years, in the territorial department, I conduced a "Group-analytical psychotherapy" in which I had inserted some people by me a long time individually treated and besides some other patients that had begun with me a psychotherapy foreseeing weekly one individual session and one group session.
Evidently it was a group, from the clinical point of view, for so to say soft, because the participants were outpatients without serious psychopathological disorders. For some of them it can be affirmed that they have definitely overcome the neurotic troubles for which they had begun the individual psychotherapeutic treatment and despite this they felt the need to keep on enjoying of a context that facilitates the psychological elaboration.
Not unproblematic was to accept by every person the entry in the group. The initial perplexities towards the group-psychotherapy are justified by social-cultural reasons as the insufficient open-mindedness in a territory that only after various years is above all receptive to the individual psychotherapy. On the purely psychological plan, we have to consider the intervention of some comprehensible factors as the fears about the privacy and the intimate; these matters can arouse in a number of people a lot of perplexities to the idea to expose some individual problems in presence of a public even if this is constituted by a narrow number of people tormented by similar problems. The other factors can be connected to the imagination of an exclusive therapeutic relationship with the psychotherapist, to the jealousy towards other patients and to the emotional feelings linked to the oedipal conflict. At a level more deep we have to also consider the unconscious competition inside the individual between family and group. By my experience, I can affirm that more the person is enmeshed in critical familiar dynamics more will have various resistances to the participation to a group; evidently, the "internally introjected pathological family" is to consider as a group self-defence operating in the, so-called "designed", family person a destruction of every alternative experience that would be able to diminish inside that individual the value of the same family. With one patient of mine, a young woman which painfully lived the particular and complicated interlacement of paradoxical situations stratified in her family, I had to wait more than three years before she decided (or before this was allowed her by the "subjective internal family") her entry in the therapeutic group; by this she had an express and tangible benefit.

9. Group for insulin-treated diabetics
One of the most interesting was the "Group for insulin-treated diabetics", by me conducted in general hospital in collaboration with a colleague, specialist in diabetic, illnesses who actively intervened in the group for furnishing to the participants, when this was in demand, various explanations about the diet or other specialist matters connected to the diabetes and, beside giving some suggestions about how to proceed relatively to the insulin-therapy.
The beginning of the insulin injection-therapy represents for these patients one of the most delicate moments during their life: this intensifies theirs sensation of a damage coming from the inside of the body linked to the hyperglycaemia and to the hormonal pancreatic alterations; more all this opens a life perspective as endless slavery to the syringes, to the glycaemia extemporaneous controls and to the exasperating verification of an alternate welfare-discomfort state in relationship to the assumptions of food, to the habits of life, to the existential events.
The delicate interlacements - inherent to dynamics as oral voracity-frustration, food-transgression guilt, dependence-independence, together with the substantial not-acceptance of the illness and the negative myths by the entourage produced about the diabetic disease - they permeate the psychological life of the insulin-treated patient. From these factors, beside the other individual elements connected to the personality, it originates the enormous need to communicate, to receive support, to attenuate the difference-feelings, to develop with the specialist in diabetic illnesses a constant relationship and to recover the trust and the hope in itself and in the life.
With the progress of the sessions, I have warned that for these diabetic persons the group, whose participants were young for the most part, was acquiring an increasing importance. If going on with aforesaid experiences, it will succeed in showing, as firmly I believe, that it will be possible in the majority of the cases to discover a meaningful correlation between stress and diabetes, we will have a further contribution about the difficult understanding of the mind-body relationship. More, if we will contemporarily succeed in developing in these patients a superior insight or a greater aptitude to a sort of "self-reverie" about the personal somato-psychic events, we will probably have helped these patients to partly arrest the evolution of their illness since still today it is not possible to consider a potential definitive recovery.

10. Psycho-anthrop-analytic group
Finally I have to mention the "Itinerant Seminar" on "The Symbolic Imaginary", whose beginning goes back to 1995, because at the present time it perhaps is the most fascinating group dimension that I know. The "Immaginario Simbolico" is an original group model, by me conceived, it proceeds by "free associations" here and now beginning from a visiting a much historically and/or culturally, besides natural (that is not on purpose constructed), suggestive place and spontaneously self-developing according to a "working in progress" method; in fact any introductory relationship or any preconceived stimulus is programmed if not the magic of the place. More, the "Immaginario Simbolico" allows the achievement of psychological dimensions relating to archetypal profundities therefore it can be also considered as an original psycho-anthrop-analytic training. So actually the Itinerant Seminar is the most original and advanced research finalized to understand the human individual and collective complexity, because, interconnecting each other the today's culture to the cultural matrix of historical Self, it realizes a trans-cultural and trans-generational "short-circuit", or rather between onto-psycho-genesis and phylo-psycho-genesis.
Evidently it is not difficult to realize what test can represent also for a yet experienced psychotherapist the conduction of a so extremely psychodynamic group as the "Itinerant Seminar" on "The Symbolic Imaginary".
Now, as in the beginning of this dissertation, I can return to ask me: am I essentially individualist or inevitably am I group-oriented?
The answer is partially traceable probably in the argumentations with which I ended an old article regarding the therapeutic groups: other types of group situation came to my mind; similar to those meeting and reunions among friends or acquaintances ordinarily observable in the public places or in the parties or in the living rooms. Reunions in which it is totally neglected to question and to discuss about the interpersonal life "in itself"; in order to understand and to improve the quality of social life; at least relatively to the quality of affiliation-group life.

11. The work-group
Apparently I have forgotten to talk about another type of group which characterizes the "institutional field": the working group, the équipe, matters on which not a long time it is concentrate a certain part of the research within the mental health. Simply, I have not wanted to speak of it! Because it is necessary to find new équipe formulas, I think, in relation to the public sanitary service.
In one historical period, as the actual global philosophy proposes, characterized by "budgetary" and "corporate" matters, the mental health reorganization in many little unities - more limited in the number of operators and more and more mono-professional (and perhaps more corporatists), besides presumably, as soon as possible in full competition among them - it seems extremely far the great project of the public Territorial Mental Health Service, previous conceived as unitary and locally global coordinated activity promoting the psychic welfare by the cooperation among various professionals, functionally integrating the relief work of the various sub-departments. Within the institutional field it is fundamental the research on the "work-group".
Are they still worth for the oligo-professional groups the great valid metaphors for the large équipe: the orchestra or better the chessboard, in which every piece has only one possibility of movement and a characteristic functional dynamism still? Or will we have to find a new something?

12. Beyond the circle
It is probable to discover that the not-large operational unities are able to experience a greater possibility to reach a "good group spirit", if they doesn't have an excessive vision-narrowness. So really the fourth element - it is the Soul of the polis and of every its new foundation - will be the factor promoting the birth of new ideas, of new solutions, of new metaphors! The human current doesn't know arrests. It stops a moment, adapts itself, learns from the experience and starts walking again: "by the circle", beyond the circle, so the humanity likewise Promethean stretched!