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The group as the most eligible therapeutic setting for
HIV positive patients with personality disorders
by Silvia Corbella
(Membro Associato S.P.I. - Vice Presidente A.P.G. - Viale Romagna 58, 20133 Milano)
Body of the Abstract
This work is the result of a critical reflection made after more than a year of supervising two groups of HIV patients with personality disorders. Dr. Raffaele Visintini of the S. Luigi center, S. Raffaele Hospital, was the group therapist and leader. The groups of not more than eight patients included both males and females, were open and had a participating observer. My intention is to highlight the group setting as something continuously characterized by the fusion-individuation dialectic, and as the most eligible setting for this type of patient for reasons I will explain in the text.
It is sufficient for the moment to keep in mind the group therapy, allows patients to regresso to archaic levels, exactly to where personality disorders originate. Furthermore, the group as a holder allows depressive angsts to be shared and enables this patients to learn how to control their destructive drives, since as it develops it gradually generates a context in which conflicts can be faced and resolved. Group work also makes it possible to project and later integrate the split aspects of the self, so that the process of differentiation from others, through repeated phases of individuation, can initiate. The experience of belonging, which is particularly important for this particular type of patient, must be emphasized. It allows for the building up of a sense of self as a person who has the right to live and occupy affective space.
The work I will present today is the result of a critical reflection made after more than a year of supervising two groups of HIV positive patients with personality disorders. Dr. Raffaele Visintini of the S. Luigi center, S. Raffaele Hospital, was the group therapist and leader. The groups of not more than eight patients included doth males and females, were open and had a participating observer. The patients had more or less severe personality disorders, and had been infected in different ways - drug abuse, at risk heterosexual or homosexual relationships.
Before considering whether group work is useful or not with these patients, I feel it is extremely important to briefly introduce some characteristics of personality disorders. I would like to stress, above all, that the ever increasing incidence of this particular pathology, in our society, is not incidentale. Rapid social change in western society, since the second world war, has created confusion as far as the importance of reference points is concerned; added to this was a reduced availability of cohering and reparative social structures to compensate for possible failure in the family. The frequent lack of reliable models of identification in the family and social environment and the ever increasing diffusion, on television, of models, which in most cases, end up compensating this lack in a surreptitious way, by offering values which are just unreliable and superficial, does not make the situation any better. Furthermore, the gap continuously experienced between what television commercials illustrate as "necessary" and easily available and daily reality increases feelings of delusion and frustration. These feelings then stimulate nihilistic and desperate states, precisely in the sense of no hope, and deprive more fragile persons of the self-confidence neede to make plans and to try fully carry them out.
As Wilson (1980) states, the young in western societies today are "rebels without a cause". If many, thanks to reliable family environments and natural gifts have known how to maintain valid behavior within an adequate process of development, others, either because less gifted or because brought up in particularly depriving environments, suffer ever more from personality disorders with unsolved problems of dependency which the possible use of alcohol and drugs does nothing but worsen. I realize this problem requires much more in-depth and complex discussion than the few aspects I have just mentioned, but I do not think it would be opportune to digress longer regarding these points at the moment. Moreover, I prefer not to discuss the specific etiology of patients with personality disorders which stem from multiple factors as has already been aknowledge. Instead, I would like to simply underline how today's society does not have cohering and reparative institutions to answer to possible severe inadequecies in the family environment, but on the contrary, in a certain way, worsens the situation.
My concept concerning this matter is borrowed from Foulkes' who believes macro or micro-social damage is much easier to repair in an adequate socila situation. This could be considered the first and foremost macroscopic reason why I feel the group therapy setting is the nost eligible for these patients. At this point, it is important to keep in mind, as many studies have demonstrated, that patients with personality disorders have, in most cases, suffered particularly inadequate parental realtionships in the micro-social environment, that is the family environment of origin. If this does not constitute a sufficient condition for the formation of personality disorders, it certainly is a risk factor. Furthermore, many authors sustain that this pathology originates in very early stages of development, due to the lack or loss of an adequate holding environment, which leads to particular difficuklties during processes of separation-individuation.
In this situation the lack of objetc-constancy makes it impossible to have an integrated relationship. The implication is that the object relations of persons with personality disorders are characterized by prevalent splitting, since the processes of differentiation could not follow natural developmental phases. All of this has produced a fragile-Self, a subsequent weakening of the capacity of the ego in carrying out its functions and an anachronistic use of very archaic defens mechanisms. All crucial moments of development then rebring this already unstable balance into question, and consequently increase unsolved conflicts. We can thus conclude this brief and consequently limiting digression by sustaining that this typical personality disorder pathology is an object relatons pathology. I beleive it is precisely the object relations theory that allows us to consider the individual and the group as different points of a continuum.
However, today I would like to point out some specifics of the group setting which make it, in my opinion, a therapeutic instrument eligible for this particular pathology. In understanding group thematics it is useful to think of time as a spiral. The image of a spiral rotating around an axle permits us to synthesize the plurality of dimensions and movement that constitute our temporal experience in the group. We can therefore go ahead or backwards, with the possibility of returning to the same point in relation to the axis. This occurs at different levels, since multiple levels of reality are present at the same time in each session and for each individual. I have also often stressed in my studies that a fundamental element and one which characterizes group therapy is the fusion-individuation dialectic movement underlying every session and therefore always available.
However, this concept of time as moving as a spiral allows me to sustain, that when I speak of fusion in the group I am refering not only to the possibility of symbolically re-enacting the symbiosis phase with the primary object, but also to the possibility of sharing other and more advanced stages of fusion. But, as far as patients with personality disorders are concerned, I feel that it is of utmost importance that, of the various potentials of the group, there also be that of making the participants regress to very primitive levels of experience, to where their principal problems originate. This regression is precisely to that archaic fusional phase (which Balint defines "of basic fault"). There is no distinction between the subject and object and, this in fact characterizes the primitive fusional moment in the group, in which fantasies of omnipotence emerge. This level of regression is potentially present immediately at the beginning of the group'' history and continues to be so for the whole time the group exists. Being in the group requires the capacity of putting into play mutual symbiotic zones and this is made possible by the particular permeability that the boundaries of the ego take on in the group situation.
The positive and transforming aspect of this regression, in this case, is the possibility of going back in time to the relationship with the primary object and thus enter into the area of the original fault to repair the path of the "grandiose Self" (a basis to develop the "true Self"). As well as, perhaps, for the first time, the possibility of forming reassuring fusional experiences of "holding" within the group to then be able to resynthesize and integrate partial objects into a whole object, thanks to group work and opportune therapeutic interventions. In this case the synchronicity, which should be an aspect of the mother-child relationship, becomes the prototype for group interaction.
However, a precise example of this situation is not easy to give because the experience that this regressive movement makes possible is located at a preverbal level; in this context, language loses conventional adult meaning and words are used as a sort of transitional object. As such it is not possible to refer to the exact content of a session in which the positive aspect of this archaic level of regression has been experienced.
However, it is possible to speak of the dominating emotional atmosphere which, shared by all, is usually extremely intense and characterized by trust; everyone participates, the therapist as well, in a sort of immersed "serene fusion", an experience, which many patients with personality disorders have never experienced. At first, the possibility of this phase, seems still superficial, often the pronoun "we" is used; "me too" becomes a sort of password. From this beginning of "formal" fusion, present in the new group which has only just begun to feel good together, even if in a confused way, the potential for a more authentic and deeper fusion develops as the group process evolves.
When the possibility of regressing to the kind of archaic fusion appears in the group it is important that the therapist not make the mistake of interpreting this situation. Moreover, it is not interpretable if not with a disturbing intrusive effect on the intensity of the experience. Instead it should be allowed to evolve freely so that the members and the group as a whole fully experience it, for as long as the therapist feels it maintains a therapeutic function. Otherwise, since, as I have already mentioned, the regression is at a preverbal level, there is the risk that interpretations not be understood at a conventional adult level of language, but felt as a disturbing element that destroys the harmony of togetherness. Only after this experience is completely lived out can it be metabolized and trasformed into thought.
When the positive and regenerating aspect of this expereince begins to vanish and elements which disturb therapeutic work begin to come out as well as the anxiety producing elements of the fusion tied to the fear of losing one's identity, and along with these the anxiety of the fear of fragmentation tied to emerging relationships with partial objects, only then should the therapist reveal the dangers in continuing this state and keep it under control. Since this regression is shared, it seems in my opinion, because of the greater continuity in the group to increase that sense of trust that Balint believes is fundamental for a benign use of regression, to supply a basis for an authentic "new beginning", and to stimulate the emergence of more adequate relational modalities both with oneself and with others.
The sharing of this experience, also greatly reduces the fears of excessive dependence, on therapist, which extremely regressive situations often provoke in individual analysis. The behavior of a therapist who knows how to present but not interfere in the dominating atmosphere in the group, but on the contrary is serenely immersed and in this way helps mantain this atmosphere, allows the members to understand that not the therapist, but the "group" accepts to experience that "sufficiently good" environment. It is an environment in which one can trustingly let oneself go in the regressive experience and in which the group as a whole can function as an adequatesubstitute of the primary object.
As far as persons with personality disorders who suffer from identity diffusion are concerned, this fusional situation at times can provoke anxiety and/or a defensive reaction of devaluation or flight. This is why I tend to include one or two patients with this particular pathology in a group of neurotics to function as models and a support to face this phase. But I feel that HIV positive patients with personality disorders need particular attention. In many cases, in fact, I have the impression that when one's death comes to mind as an event which is not far off in time it has an individualizing and differentiating function between oneself and the world of "healthy". This is often how, it seems, the identity of the HIV positive patients allows us to better define the boundaries of the ego and consolidate, even if with great ambivalence, that sense of identity. In this way this patients are able to face fusional moments with less anxiety then other patients suffering analogous disorders.
Thanks to my experience I feel able to confirm that a group of only HIV positive patients with personality disorders is not only possible but moreover desirable, given the reasons I have just mentioned and those I am about to mention. In fact, I found that in this kind of group the feeling of sharing is immediately present: the way of communicating is striking because of its immediacy and demand for authenticity. These elements seem to stimulate great acceleration towards much deeper levels of communication so that the affective circularity, the cohesion and awareness of the group as a therapeutic instrument is evident much earlier with these particular patients than in other therapeutic groups. It also seems, in many cases, that although the fear of dying during the first phase stimulates deep and almost intolerable anxiety, it is later put aside to make room for the possibility of tolerating the feeling of uncertainty and precariousness. In other words, even if one does not feel healthy, if one is not well, it is however possible to "feel good".
It is natural, in this situation, to ask oneself the sense of one's life and find that meaning. Lazzari, Campione and Chiodo (1993) believe that: "To free oneself from the tormenting and ever-present thought of an uncertain future full of painful surprises, some HIV positive patients dedicate themselves to new activities, in sentimental, occupational, and recreational areas of their live. One witnesses, in other words, a psychological "growth", a sort of "experiential illumination where every aspect of oneself and of others takes on new significance, unexpected, but true". It seems, somewhat a paradox, that the thought of an "announced" death permits these patients, perhaps for the first time, the awareness of having a right to live, to a valued life. The cohesive group further stimulates the request for this right trough sharing and support. In fact, apart from obvious individual particularities, the members of the group which I worked with a supervisor, seemed to have some common aspects regarding their personal life history. In particular, what deeply impressed me was that as the group work developed, as they communicated their past and present life history, little by little, for each of these patients the fact emerged that there had been a message from their environment of origin, not necessarily explicit, but precisely because of this even more dangerous, of not having the right to a valued life, but at most of surviving.
In fact, they were either almost all unwanted children or had had very absent and/or particularly narcissistic parental figures. The latter consider children only a narcissistic extension of themselves, and therefore fully accept them only and only if they answer to their expectations, otherwise they give signs of intolerance or delusion. So these patients never felt wanted, and wanted for what they actually were, but had to take on suitable behavior or one falsely complacent and/or reactively transgressive.
Other members of the group, instead, had had parents with severe pathologies, at times even with specific disorders such as alcoholism or drug addiction; none of them had had "sufficiently good" family environments nor parental figures who could have acted as reliable and valid models. In fact, my use of the term "environment of origin" and not "parents" was implicit, because, in some cases a real and true family of reference was actually lacking and instead there had been more or less inadequate parental figures. These persons, even before having become HIV positive felt like "marked" persons and not in the banal social sense of the word but, as Zucca Alessandrelli (1995) writes: "The "mark" is the primary terror of "not being" as a person, that is of not being significant and valuable as the subject-object of a vital relationship... . As the possibility of facing fundamental transformations abd thus separations and, the need to abandon roles without limits. They battle with the fact that they actually have to accept, at a very vigorous age of life, the possible end of an "object" fundamental for every one of us: our own life. And yet, precisely with the approach of this incredible danger can the possibility emerge of reproposing their request to be significant."
As I have already mentioned, I feel that the therapeutic group is the most eligible setting to receive this request. The group in fact in becoming work, is considered by the members as an extension of the self, and as a place where they can be and say, look, listen and understand. The feeling of belonging to the group is particularly important for this type of patient, since it is fundamental for the building of a sense of Self, as a person who has the right to live and to have affective space and one in which to be listened to.
I would like to underline, regarding this, that the group, as Neri (1995) also states, often takes on the fundamental function of Self-object. An object which makes the Self of the individual emerge and maintains it and gives it significance. At times it takes on the role of twin Self-object which thanks to the warm and affective presence of other persons gives an essential contribution to building-up the feeling of being, of being "a human being among other human beings" and for these persons who so often feel "different" this is very important. I would also like to stress that the experience of a relationship with a twin self-object is much stronger and meaningful in a group situation than in individual therapy. In the group, in fact, just the fact of seeing each other and being many, makes the bodily presence of others much more concrete and explicit, and stimulates the awareness of belonging to an active and functional meeting.
All of this, however, in particular with HIV positive patients, should not be interpretated but, as in positive fusional phases, should be allowed to be experienced. One should keep in mind that, for this kind of patient, a ficilitating and welcoming environment represents even if positive something "new" and unknown, and as such is frightening and induces defensive reactions, even that of not attending the group sessions. But this "acting out" that a patient may choose to express, is also valuable and important communication for all the members of the group. In fact, when patients who have "acted out" this fear which is also that of the other members, return they are accepted in an environment, which contrary to the past, neither looks down on them or bans them, but instead gives them importance by helping them understand how they took on hte role of "those who are afraid of the new" for everyone in the group. It is thus possible to highlight that the fear of the new is a lived and shared experience that thanks to this "acting out" becomes communication that permits awareness and elaboration. These patients and the group as a whole are reinforced by this experience, given the sharing of the awareness of being able to be understood as well as being able to do something for others.
Regarding the important use of the role of the group I would like to refer to my paper (1988). As for the fundamental function of the group as Self-object I would like to call to mind that the group takes on an ideal and omnipotent Self-object role, as always occurs in a positive fusional phase. This object is idealized but not distanced, on the contrary it is experienced as an extension of the Self and allows to experience being a whole with an ideal of calm and strength. It is clear that from this phase the patients must later pass, and not only once (spiral time), to the healthy phase of individuation. But it is important that this passage, contrary to what has occurred in the past for most of these patients, not be traumatic and radical but gradual and shared and that this experience remain in the history of the group as a reservoir of energy accessible in moments of hard work and difficulty.
"The group as an ideal Self-object therefore, makes a certain amount of shared and accessible "omnipotence" available" (Neri 1995). Furthermore the group as ideal Self-object can also offer a joyful and participating reflection of the positive conquests of the single members, by forming and maintaining a good image of the self. This, by removing desperation, regives hope and encouragement for new projects, in an environment of deep affective participation. In fact in a well functioning group the awareness that the success of one member is the result of everyone's work os always present and becomes part of a mutual and shared history, since the happenings of each single member are enclosed in the history of the group. The history of the group also allows new members to share this trust, at least through empathy, to be able to face and resolve problems together. Another of its functions is to alleviate the tension produced in particular dramatic moments. This occurs when comforting accounts of conflicts already present in the past and unresolved, and analogous to those experienced in the hic et nunc of the sessions are provided and thus consequently reduce depressive anxiety.
Usually the "historic" account is that of patient who in the past was the spokesman of problems which are re-enacted in the present and who can now look back in a detached but aware way. Another example is the account of a subgroup of patients, who have assisted and participated in a common task: even if, of a subgroup, at times, in groups where the patients are not HIV positive, some of the patients who were spokesman have already finished the therapy. In the HIV positive groups instead the memory, most of the times, is not of patients who have suspended or terminated the therapy, but of patients who have died. This is precisely ehy the history of the group is of utmost importance in the case of HIV posivite persons, since it also takes on the function of remembering the journey traveled by all those who participated in the group and of maintaining this memory alive. The awareness of this is of great comfort for these patients.
Therefore if the historic-community dimension in group work is a specific therapeutic factor, which promotes the development of both the individual and the group itself, in HIV positive groups it has a fundamental and indispensable function. History of the therapeutic group allows patients to go beyond the splitting and episodical aspects of the Ego, to share univarsla human experiences. It also allows patients to achieve a positive synthesis between the synchronic and diachronic prospect and thus produce a reverse movement but one complementary to the on towards individualization. Consequently, it also provides the foundations to overcome the fear of separation and solitude, since it ties the individual to others.
Naturally all the above is also true for HIV positive groups, but for them history is much more important. History assures them that they will leave "a heredity of affects" in an area of belonging. An area, where their right to a valued life has been acknowledge and shared, and where consequently the need and right to the value of death can also be acknowledged, as an indispensable event for all human beings who can be spoken of, and not as the result of a personal fault. This aspect makes the therapeutic group setting different from all other social settings. Today there is the tendency to negae death in a maniacal way and to accuse and ghettoize HIV positive patients also because they represent a concrete "memento mori".
In group work even the therapist must know how to face this reality in an authentic and deep way and guarantee the patient that the group as a whole knows how to maintain the memory and testimony of a valuable and significant existence. It is not a coincidence that when new patients join an HIV positive group or when new groups are formed, which also include patients who have participated in groups and for various reasons no longer had a sufficient number of patients, there is a patient who takes on the role of "aedo" of the group. This person becomes spokesman of the past history and revives the memory of persons who are no longer there and in certain way tests the therapist to check if these patients are still present and will remain present. Moreover, it is not a coincidence that in these groups more than in others, special events are celebrated that in the family had often never been adequately celebrated (as Christmas and Carnaval): in these occasions photographs are taken and given to all the participants and therefore as well to the therapist and observer who keep them for the group.
Frequently, a supervisor is necessary as a reference to conduct these groups. There are many difficulties to face and the involvement requested from the therapist is particularly deep and authentic. Therfore the regualting of emotional distnce neede to face certain themes that come up from time to time in the best possible way is problematic.
There are many things I would like to say regarding the specifics of this type of group and there are many instances I would like to refer to, but given the time limit, this is, unfortunately, not possible. I'll only say I believe is important to be conscious that these are therapeutic groups and not groups to accompany patients to a "good death", because I share these patients right to a valued life and to the understanding of the meaning of life before being able and having to face that of death.
Just recently in one of these groups a patient who had terminated his therapy left, as a gift to the group, the hope of being able to leave the group because one feels well and not only because one is afraid of the group and flees, or because he dies. Naturally this is not denial of death but the ability to see and face life together. The indissoluble bond life/death is well expressed by Sini: "let us remember that apart from public knowledge, apart from this fact that is considered unthinkable (death), which among other things opens the doors to the fantasies of thought, apart from all of this, eternally, continuously victorious over this thought is the enchatment of life, the enchantment of each instant that faces the thought of death, that alone defeats it in every moment, in an omnitemporality which can certainly not do without death (its other side), but which is not less strong, not less penetrating, not less powerful and, above all, not less human".
I feel therefore that I can conclude that the therapeutic group, thanks to the specifics I have highlighted, supports HIV positive patients in making death regive or give for the first time a sense of self and ones importance as a person, a sense of ones unrepeatability and uniqueness as a human being and let the passage from "infinite" time of the healthy subject to the potentially limited time of theHIV positive subject be a passage of more careful examination of the hic et nunc, of the real positive potentials that life can offer.
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