Working through group psychotherapy with adolescents implies creating the necessary and sufficient conditions for the "cure": the group process is the natural social context within which individual change will occur.
From our point of view, creating these conditions necessarily implies including in the task the investigation of some etiological factors that, inevitably, in the therapeutic process, will lead us to the evidence of traumatic events (both isolated events, and sustained situations over time). It can be seen that practically all these events have taken place in group or collective contexts. Taking into account the clinical evidence, the “peer groups” in puberty and adolescence are the main promoters, or at least experienced as such, of these overloads or insults on narcissism that hinder the construction of identity and adaptive processes.
The psychotherapy group, having specific characteristics, an operating method and some “rules of the game” (setting), becomes a “safe” social setting in which these events of personal history can be worked on: “the group as generating agent ”vs. "The group as a corrective agent".
In this micro-social dialectic, developed through the coordinator's hermeneutical procedure, different therapeutic factors act on the traumatic (Inverted Cone Scheme):
Inverted Cone Scheme
- The development of a feeling of belonging, antagonistic to isolation and the feeling of melancholy and loneliness. Vector Membership.
- The common work on the task that brings them together, leaving out prejudices, value judgments and discrimination. Vector Relevance.
- Social cooperation from personal difference, and the establishment of new links overcoming previous stereotypes. Vector Cooperation.
- Possible and fluent communication about feelings and blocked events that have not been able to be metabolized in other times and settings. Vector Communication.
- Common learning about the functioning of human psychology itself, the factors added, or artificially acquired, to natural suffering, and the healing mechanisms now learned on the same level of equality. Vector Learning.
- The destruction of prejudice through knowledge of the other, in a speculative way and from a perspective that goes beyond what is already known. Vector Tele.
THE OBJECT
The epistemology of child and youth psychopathology forces us to place ourselves before the authentic object of knowledge, the subject in development and in integration with their systems: biological, psychological and social.
It is not admissible to think and act clinically on assumptions that dispense with the adequacy of existing theoretical models to the object and their research methods and clinical practice; that is, we must do so from a comprehensive reading of what we are observing from the perspective of change and interdisciplinarity. Any psychopathological manifestation is, after all, the only possible behavior of that subject, in those circumstances and at that specific moment. Actually, a still from a movie being shot in the here and now.
The non-epistemology of classical psychopathological taxonomy is particularly counterproductive when used in childhood and adolescence. The classification predisposes to stereotyped forms of clinical management, and may even suppose an indelible mark that will mark the subject for life. This can make us forget that we are facing an unfinished phenomenon, in motion, in constant development and change. A plastic set where there are no diseases, but still unfinished subjects, an emerging quality of a social genetic micro system.
From a metapsychological point of view, symptoms provide information about the disturbances that occurred during each person's learning process (life events and "emotional overloads"). In other words, about experiences that the psyche could not elaborate at the time in which the life situation occurred, due to interference in communication in the family and social setting. In short, these symptoms are capable of signifying a deficit in the linguistic processing of emotions.
The phenomenological expression of the symptom crystallizes a latent traumatic nucleus or "Basic Depressive Situation" (Pichón-Rivière), which is under the repression of consciousness through the defense mechanisms of the psychism (fundamentally denial-denial-, dissociation, negation, displacement and projection). Thus, frustration and the associated aggressive drives are sustained in the body and over time, giving way, as a probable first option, to alexithymia, silence in response, in situations of acute stress or emotional trauma, which will be consolidated as psychic, and on a basis of vulnerability fundamentally given by circumstances and age. Therefore, our task is not only to interpret this response, but rather to translate it into the verbal.
The basic depressive situation is inherent to any emotional trauma, or borderline experience of necessity (Rosenthal), it usually leads to the paralysis of the instrumental defenses that remain in latency, to later move to genetic pathogenic positions and the configuration of clinical pathoplasty. This is, in synthesis, the core of the "Unique Disease Theory," which in addition to providing a model for understanding individual and social psychology, supports the technical principles of the "operative groups" method.
In this sense, the social pathoplasty of eating disorders, considered as psychosomatic disorders, represent, with their symptoms, the inalienable human experience in the face of desired love ("ego ideal", Freud) and its hypnotic deficiencies. Affection as food for the soul, love as soul for the body, the depth of the skin as an envelope for the body, are paradigms of the complexity of these forms that narcissistic wounds acquire, and which is shown as melancholy that inhibits development (“el love is too young to be aware ”).
THE METHOD
Having exposed these considerations on the object under study, we propose the institutional and integrated method of psychotherapy that we implement and have been using, personally and professionally for forty years, and since November 1996 at the “Niño Jesús Children's University Hospital” in Madrid (*), through different group organizations, which cover the biological, behavioral, family, social and psychological aspects of each subject at a given moment, and which, due to their empirical value, allow the analysis of the reciprocity between text and context. This practice is based on the creation of open and plastic groups that allow the incorporation of new patients and the transition to other levels of treatment depending on the characteristics and evolution of each case. Due to the critical mass of the resulting organization,the operating forces of the conditioning mechanisms of the Institution and the created system are synergistically incorporated, giving rise to a dynamic, integrated and integrating learning process.
Through the systemic method, it is intended to model the object by acting on the relationship between its components (structure and dynamics of the whole). This treatment organization system is based on and articulated in adapted group methods, using the various forms of relationship fostered by the system created. It can be considered as an institutional approach and a relational psychotherapy developed in successive stages at different levels of integration. Therefore, this system considers, necessarily and fundamentally, the treatment of attachment bonds and the personalities frequently associated with the disorders addressed.
The specific model achieved -treatment method-, must be isomorphic to the object; that is, an institutional system of continuous and integrated intensive care, which encompasses the somatic aspects, the primary attachment relationships and the groups of belonging, so that the patient's reference groups and the psychic organization of each subject are related to this clinical social context.
The objective is to provide an artificially created link space in order to investigate and favor the development and / or modification of disturbed and pathogenic links that occur in early learning. In this way, we generate a different form of, and through, a specific type of socialization that is achieved through the therapeutic group and the reciprocal relationship of influence.
With the use of the link as a reactive concept, we create different moments in a virtual, symbolic, imaginary space that allows us to deepen the treatment in an intensive and brief way, and at the same time, it encourages the creation of new opportunities for social interaction in a climate acceptance and tolerance.
The resulting system can be considered as a continuous space and time, "a parallel film" (the parallel life of dreams), where the personal dimension (vertical coordinate) and the group dimension (horizontal coordinate) converge, confluence of behavior, and in which the perception of the other and of the self is facilitated: "I am you, you are me", since the interaction of the group returns to the patient multiple images of himself (specular phenomenon). The perception and confrontation of one's own somatic existence (the bodily self) is thus consolidated in communication: "The body creates space like water in a glass" (Iel-Hakim, cited by Sami-Ali).
In that space and in that treatment time (the Hospital, the inpatient ward, the day hospitals, the outpatient treatment and the interventionist follow-up), in synergistic synchronization, the transfer and the imaginary symbolic projection of scenes are generated and developed. Biographical relatives who acted as triggers for readings that condition the current reality.
In the family group there is primary learning, the form, the signifier and the meaning of a common denominator with universal frequency, which evolved into a certain type of "affective warp" (Rof Carballo). That physical, emotional and social envelope in which the subject develops body, feeling and mind; the nest and attachment, with their definitive evolutionary functions, is the one that is repeated and revised, “here, now and with me”, in the “group matrix” (Foulkes).
The therapeutic approach to these biographical realities in the group warp, the interaction and relational deepening, and the conditions of clinical work (setting), operate as hypnagogic factors that facilitate the fall of repression and the appearance of expressed emotion. This being the case, an excellent opportunity is presented in this context for the symbolic elaboration of the traumatic; an imaginary journey towards that space-time engulfed in the black hole of the psyche, the unconscious, and finally, the depression of the cure.
The dialectic of that struggle between Eros ("love") and Thanatos ("death") is recreated in the therapeutic space, united to the being of language, perceptible in time, as a succession of phenomena that go irreversibly from the memory of the past to the projection, towards the prospective of a future, until now, probably non-existent. In the end, a carrot is presented for the donkey, a sense of the walk in life.
In that climate and in that texture created by the group itself, emotions are expressed through words, the imaginary is collectively rewritten. In addition, new orientations of the libido are mobilized, in the exchange of biographical experiences, the banal, the superficial are discarded and the possibility of releasing the encrypted in the reservoir of the body and in the deep speech is given.
In this context, the possibility is then offered to mentalize, to unite the inherited biographical darkness, to the possible light projected in the psychotherapeutic space. To achieve this, the therapist must show the ability to bring the focus of space and time closer and further, in order to understand and make the patient and their group understand the process, integrating the experience through language and suturing the dissociation that underlies the suffering. And the most complicated, the operational coordination of the family groups involved, the clinical system and the mother institution (in our case, son: the “Niño Jesús University Children's Hospital”).
CONCLUSIONS
In the psychotherapy methods of the 21st century, new concepts are glimpsed in systematized treatments, at least in adolescent problems, with a paradigm shift that progresses from clinical semiology to social semiotics.
Perhaps we approach and also find another cultural and instrumental model of the mystical, where soul, psychism and body are shown to us as complementary aspects of the same reality. Real and imaginary in dialectical process, in reciprocal relation of influence, perception and projection: expressed emotion and psychic work in a social group revolutionized in the new forms of non-communication: the signifiers of "inflamed egos" (Mario Andrade), perhaps because they are deflated, if so, it has an easy cure: air, water and good conversation with quality peers. Emotional memory vs. rational memory.
Inverted Cone diagram: the intrinsic forces of the group (Pichón-Rivière)
The Operative Group focuses on the manifest task of change and the removal of obstacles to knowledge, it does so through the systematic analysis of unexpressed and latent emotions, in a process of group dialectics.
The group system evolved during its development into the following group outpatient modules (MAG) integrated, stable, simultaneous, consecutive and random according to clinical evolution):
- Life Plan Group Psychotherapy Group Parent Group Group Group (Multi-Family Groups)
