Introduction, Group Psychoterapy with Psychotic and Borderline Patiens

I am honoured to present the fourth number of Funzione Gamma Journal edited by my Italian colleagues and me, about “group psychotherapy with psychotic and borderline patients “. The Funzione Gamma Journal has met with remarkable success, presenting papers coming mostly from a European tradition; with this number we establish a profitable, communicative connection with North America.

I hope that readers will find the same stimuli and interests that we felt in writing the papers contained in this issue.

Howard D. Kibel, M. D.

The papers enclosed in this number of the Funzione Gamma Journal reflect the increasing need for an exchange of clinical and theoretical experiences coming from different contexts in such a way as to permit the amplification of the cognitive instruments used in group psychotherapy. The authors illustrate, with their contributions, the practical and theoretical planning used in their clinical experience of group psychotherapy. The North American authors present models that can be linked to the institutional context and with the general problem of patient care. They have been able to elaborate models of group treatment, working in different contexts, considering how the planning of each treatment model adopted is connected to events that also happen in other levels inside a major extended treatment program. In his paper Howard Kibel gives a definition of the “difficult patient” in a group.
Kibel uses elements coming from both the theories of object relationships and self-psychology. Kibel points out, in order to let us understand the psychopathology of these patients, how the integration of parameters in the treatment, coming from both these theories, can cause an improvement in the therapeutic process with this type of patient. Kibel emphasises how difficult patients not only can derive benefit from psychotherapy, but also that they can be good for the psychotherapy group itself. Difficult patients in a group, because of their interpersonal sensitivity, can respond to subliminal affects in others, limit feelings for others and behave as repositories for projective identification. In groups with difficult patients the leader has special importance. He has to do precise work to improve the therapeutic union; the difficult patient, personalizing elements from a group union, can change or even replace previous pathological identifications.
Walter Stone presents a supportive group therapy model defined by flexibility of the group boundary; this flexibility takes into account both the dynamics of patients with chronic mental disorders and the setting of the group itself. Inside the group the flexible participation makes the therapeutic context more suitable to and respectful of this type of patient. The serious and persistent mental disorder interferes drastically with the standards of an individual’s life, thereby putting into the discussion the primary aspects of every day life. Group therapy helps chronic patients (to) maintain satisfying personal relations. This factor decreases relapses and, as a result, it produces an improvement in the standards of life.
Hassan Azim presents partial hospitalization as one of the most effective ways to treat patients with personality disorders, The author deals in depth with programmes for daily or so-called day treatment (service) distinguishing them from two other kinds of partial hospitalization: day hospitals and day care services. Habilitation and rehabilitation have fundamental roles in this sort of treatment in order to help the patient develop skills, so as to attain the highest level of autonomy of which the patient is capable.
The two papers by David Brook and Paul Cox emphasize, in a particular way, the problems with care systems in the United States. Both the authors suggest that the group be used as a support for medication treatment .The main aims of groups described by Brook and Cox are not focused on psychodynamic problems; but rather on the promotion of assent to the medication treatment and so to the removal of resistances that have practical consequences. The most remarkable characteristic in the groups described by Brook and Cox is that in this type of group we usually find two or more co-leaders; for Brook they can be a psychotherapist, a nurse and a social worker, while for Cox they are always two psychotherapists. Brook focuses on the results of medication treatment; Cox is interested in the impact that the treatment has on the patient’s subjective experience.
The Italian contribution presents a modelling of the small group with analytical finality in an institutional context and in a private context. They draw our attention to the “movements,” to the “phases,” and to the “position” that the group engages and goes through during the curative process. The group is a place of “deposit”, where to “work through”, “transformate”, but also a privileged place in which patients regain those primary functions that will allow for self-reintegration.
The Stefania Marinelli’s article, describing a group’s experience that takes place in a private study, treats a theme which is not developed very much in the group psychoanalytic literature: the depressive position that is experienced in the group. Marinelli postulates the existence of a group’s depressive position that develops and proceeds differently from that in the individual setting. In order to work-through the depressive position, the group must pass across some moments of “rite collective”. In the beginning a “disclosure rite” and of “groupal recognition”, afterwards a “funeral rite of departure”. Passing across these collective burial rites, the group’s mental and affective texture allows the working-through of the mournful elements that accompany transformations.
In their contribution Antonello Correale and Patrizia Masoni, describe an experience with a psychotic group of young people in a Curative Residential Institution. The authors try to apply two fundamental concepts of contemporaneous psychoanalysis to this group: the concept of “position in group” and the concept of “model scene”(in Lichtenberg’s sense). The subsequently described positions are 1) a “not differentiation position”, 2) a self-reflectiveness position”. In this last position a sense of personal recognition together with an awareness of their own needs starts to emerge in the patients. All this on one side facilitates individual development, and on the other risks breaking the group’s unity. The model-scene could be a curative strategy that is useful to favour individuation in the group by engaging characteristics and particular functions according to the phase in which it appears.