Raquel Vidal Arandes
Psychologist, Psychoanalytic Psychotherapist. Post-De- gree in Neuropsychology and Dementia. Graduated in Fine Arts. Working both individually and as a group therapist for over 20 years. Member of the AEPP (Asoci- ación Española de Psicoterapia Psicoanalítica) and FEAP (Federación Española de Asociación de Psicoterapeutas). Delegate of the Group Section at the EFPP (European Federation for Psychoanalytic Psychotherapy). Teaching at the Emotions Seminar at ACPP/UdG (Universitat de Girona) since 2013. Currently and since 2011 collabo- rating with la Fundació Sant Peter Claver from Barce- lona in the Psychotherapy Groups Research with Elderly Project.
Paper presented at the VII Symposium held in Zaragoza by the FEAP (The Spanish Federation of Psychotherapeutic Associations) on 2 and 3 October 2015 and published in La Revista Catalana de Psicoanàlisi, Vol. XXXIII / 1.
Raquel Vidal Arandes
Close to Death.
The Reflections and Experiences of a Group Psychoanalytic Psychotherapist working with Elderly People in an Institution
In this paper I would like to present the experience I have had as a psychotherapist, working with a group of elderly patients in an assisted living facility. I have il- lustrated this experience with four clinical vignettes and the pictures that often come to my mind when working with these patients. I have attempted to explain how death anxiety, along with a massive and overwhelming sense of loss, predominates in this group. I have also endeavoured to show the predominating defences
that are used, and what I think should be the role and function of therapists who work with the elderly in an institutional environment.
Anxiety, defences, death, loss, geriatric facility, old age.
Objective and Characteristics
The aim of this article is to explain my clinical experience regarding incidents that arise in a psychoanalytic inspired psychotherapy group with elderly people who live in an institution. I will also try to outline my role as a psychotherapist, through the use of images that come to mind when working in group sessions. Why pictorial images? In the words of Umberto Eco (2002):
“There is that which is ugly and repugnant to us, but which becomes acceptable and even agreeable through art, that which expresses and denounces ugliness with beauty, in both a physical and amoral sense.”
Does old age and beauty mutually exclude each other? Within our group there are three inherent characteristics to be considered from the beginning:
1. Its members have an average age of 88.
2. These members are ending their lives within the institution; they will die there. The members of the group witness and suffer the death of other members. Like a chain, they also see the regeneration of the group when new elderly people join, as they enter the institution.
3. It is an open group, whose people members stop attending sessions for insuperable reasons such as serious illness or death.
What is the purpose of carrying out group psychotherapy with elderly people who live in an institution, one that cares for them from entry until their death?
These reasons will come to light as the paper progresses. I will illustrate the experiences that take place in our group work with clinical vignettes within the context of a healthcare residence.
The paper is structured around death and the massive experience of overwhelming loss, losses that have their maximum expression in death itself, which is neither more nor less than the loss of life itself. This fact is as natural as it is heart-breaking, and we find ourselves before a group that consists of people in the final stages of their lives; each one of the members has their own existence, one that makes this final stage different from that of the others, but they also share a common destiny in the near future, that of dying. How does an elderly person feel this closeness to death when they have been admitted to an institution from which they will not leave alive?
Death is the central core of this paper, just as loss gives meaning to the existence of the group. As these losses emerge, one witnesses an almost shameless display of fear and defences with respect to the final and greatest of all losses, that of our own existence. Different types of losses arise that we attempt to process within the group, session after session: the loss of physical and mental abilities, which often involve the acceleration of dementia, the loss of one‘s home, the loss of family and social ties, etc. However, I will be directing my focus on the greatest of all losses: the loss of one’s own life, and the defences created within our psychotherapy group and around it.
As mentioned above, being in a geriatric institution is in itself a peculiarity, a differential fact: in this type of institution, the elderly live there until the end arrives. When a person enters, they know that they will not leave the institution unless they go ‘feet first’, an expression often used by the elderly themselves. The overwhelming and invasive presence of death is ma- nifest intermittently and mobilizes both individual and group work defence systems. Death anxieties are often devastating. Personal defences are also difficult to deal with: it is difficult to talk about that which creates so much fear. Death gives meaning to the psychotherapy group, from there, the therapist will have the opportunity to find their place. It is a group of dispossessed, a group of castaways adrift, who are looking for a meaning, an existential one.
At a counter-transferential level and due to the successive supervisory procedures undertaken, it became evident that as therapist, the images that emerge in response to massive group transference are a necessity. These images will initially help me to comprehend what is happening inside the session and I will be able to respond to the group as issues arise, so that latent anxieties can be metabolised as much as possible. This is a mode of self-defence that I will use as a resource in my approach to Bion’s reverie function, something that is useful to implement as a therapist.
Losses and Defences. Vignette 1
In a session held in February, Trini, a female patient, explained her experience of accompanying her own daughter in hospital who later died. Trini explained one of the most painful losses that any human being can suffer: the loss of a daughter. Her daughter, aged 60 at the time, had a serious mental illness. She lived in a mental institution of the region. She underwent a surgical intervention involving the drainage of the cerebral ventricles, a serious operation from which she did not recover, as other disorders were also involved. She died shortly afterwards.
After talking about the process for some time, Trini said:
“People at the hospital said that a man had been operated for a stomach problem and doctors took out the guts and put them on the table to get rid of the problem. They left him empty, and then they filled him back up without the problem. One way or another, they get rid of the problem, but what a way of doing it!”
While she is explaining everything to the group, she makes unpleasant gestures with her face and hands. I think how powerless and dispossessed this woman must feel, when speaking about how doctors could empty somebody out, leaving them without anything inside, but then refilling them with the problem taken away! I think it’s a wonderful metaphor. But I say nothing. I do not want to interrupt the flow of the group. Another member, Gerard, suddenly speaks up, “I was operated during the war without anaesthetic and they took the problem out!” He explains in detail how the doctors removed the shrapnel that was scattered throughout the right side of his body. His speech is followed by a long silence.
Trini is the spokesperson for group anxieties, for those members who, during the course of the session have been talking about problems, pains and physical losses. As she talks, Trini gives voice to a group that feels empty, stripped and gutted. She is a 91 year-old woman, she has just lost her daughter and she is the voice of a group full of pain, with their guts on the table. Empty. These mental guts should be returned to their inner world without problems: this is the idea that Trini metaphorically verbalizes, while Gerard shows us a pain for which no anaesthesia is possible.
The anxiety that she shows is so overwhelming that a long silence ensues. A long silence in which it is also evident that another form of defence exists: Joana has fallen asleep. And sleeping is also a way of disconnecting. A defence.
When this fact is revealed by Paco, another patient, who points to Joana while laughing, Joana opens her eyes and tells us that she was not sleeping: she was remembering a weekend she spent in the town of Viladrau. Then she begins to explain what happened on Sunday, which is another defence mechanism, an escape, as a means with which to evade the present. There are three ways these people defend themselves against what is so poignant and painful: silence, sleep and evasion. But, to be faithful to what happened, the group also revealed a fourth defence strategy: that of giving the floor to one of its members, in this case Gerard, who, in a manic tone, unloads a lot of information and lets all the other group members off from taking part, while at the same time rescuing the group.
The difficulty to talk about the overwhelming anxiety that death causes the group members once again becomes evident, resulting in avoidance of issues and psychological withdrawal. As therapists, the group is offering us the fantasy of removing the problem. If this is not possible, how can we transform this information into something that may be in line with the alpho bionian function (Bion, 1979)? How can the group’s experience of dispossession and emptiness be returned to them in a transformed state that is digestible and profitable?
Surprisingly and in a very accurate manner, the answer comes in the same session from Jaume, a 92 year-old man who in a free association of everything that Joana is displaying – connects the concept of strangeness to bees when he says “as rare as a bee” (in some kind of traditional local saying) and from then on he creates an excellent metaphor of what we are doing within the group:
“It is the liveliest of animals: it works all summer for the winter. The pollen trapped on their heads and legs when they suck on the flowers is brought to the hive and they make honey. They transform everything.”
I then add the following reflection:
“It seems as though we are trying to do the same when we meet in this group, aren’t we? We work for the winter and then the cold comes, death… Transforming everything…”
I am touched to see how the group is able to reach these conclusions. I keep listening. I think this bee/group metaphor is very interesting.
An Open Group that dismembers itself and survives. Vignette 2
Our psychotherapy group is an open one. It aver- ages between 10 and 17 members. There are many ab- sences due to insurmountable health reasons associated to physical and mental frailty: falls, sudden hospitalizations, obvious processes of dementia, etc. And although these absences are often occasional they also represent losses. Losses that highlight the central loss mentioned earlier.
In one session that takes place on an Easter Monday, there are seven absences: there are four people confined to bed, two people in hospital and one has gone to the doctor. Trini, who is 91, feels completely exhausted after having buried her daughter; she has completed all the legal paperwork and she has also been present throughout her daughter’s illness. Maria is in bed after a hospital stay lasting more than ten days. She has come back to the institution with a poor prognosis: she is terminally ill.
Montse is in bed with severe chest pain, the result of a fall.
Antonia, like Maria, is in bed after having been in hospital for a long time. She is suffering from multiple diseases and her prognosis is reserved. Pau has also been sent to the hospital because of a severe illness that causes immobility and stiffness in his joints and muscles. Jaume was hospitalized with an acute state of confusion and disorientation, in addition to a highly structured persecutory delirium. This could be early signs of dementia. Josep had a scheduled visit to the ophthalmologist because he is losing his sight.
The session therefore begins without these seven people. There are ten of us in total, counting the therapist. The group is falling apart. Today we have a dismembered, chopped-up group. The images of a fragment of a work by Hieronymus Bosch The Garden of Earthly Delights come to my mind. Especially the right side of the triptych: Hell.
I have enclosed a section of the work, which to me illustrates the harshness of being in a group that is so obviously falling apart (Figure 1). I see it as a metaphor of what is happening to us and of what often happens within the group.
Figure 1. Hell, a section of The Garden of Earthly Delights, by Hieronymus Bosch (15th century). Madrid: Prado Museum.
A description of the symbolic richness of the fragment would require another paper. I am enclosing it here as it is an image that I often recall in our meetings.
In the session we will see now, the reasons why people do not attend meetings highlight the fragility and loss of health in old age. The loss of physical and mental integrity. How can a body like the one in Hell be cut in half? How can a group survive when almost half of its members are missing? This question is in itself disturbing for both the therapist and the remaining group members. Equally disturbing is the act of contemplating Hell, where the apocalyptic vision of what awaits us after having enjoyed Paradise – which is the right part of the triptych – and The Garden of Earthly Delights – the central part – does nothing more than refer to what awaits us after death.
How does the group react with respect to this fact? Basically evasion arises as a defence mechanism. Catastrophic anxieties of fragmentation occur. Suffering is excessive. The group cannot speak of all the dispossession suffered here and now, despite my efforts as therapist. The group begins to talk about economic and political matters. Then, and protected by the basic assumption of attack and escape in terms of Bion (1979), the group gives the floor to Gerard, who, with his extremely manic, voracious attitude does not let almost anyone else speak, taking up nearly all the time left by telling the story of when his parents got married. He follows on with the story of his sister-in-law, one that we know from other sessions; he tells the story of when she went to live with his parents and stole all their money. I have to interpret everything because especially today Gerard is speaking in a confused way. The sister-in-law had a daughter who died at seven years old, run over by a German:
She already spoke English and French. They killed her, she was so lovely! My sister-in-law was told she had an underdeveloped womb, but after that she had two more children. And the doctor said she had an underdeveloped womb!
He repeats it over and over again. I think Gerard’s manic characteristics produce a sedative effect on the group, as their memories are very painful. These memories sedate the current reality that the group is suffering. I do not say anything at all. I just ‘translate’ his words; he keeps on talking about the four payments that the government gave to him and about how the sister-in- law cheated the entire family. Is he acting as the genius loci for the group as outlined by Claudio Neri? (Neri, 1997). The genius loci is an affective reference figure with respect to a group’s emotional heritage. The genius loci assume the task of inventing ways of being together. This means choosing – according to the moment – the emotional tone of the group (pain, meditation, joy, etc.). I ask myself if this is what is happening here and now.
Group members show expressions of boredom, fatigue. Even Trini and Fina go to sleep. Gerard does not shut up, he cannot stop himself and he goes on and on in an unintelligible, almost delirious speech.
Therapist: I wonder why Gerard is speaking? Why does the group let him speak?
Fina: Because he knows things. He probably guesses things.
Therapist: And none of you have anything to say? I don’t know if Gerard guesses things or not, but what’s true is that he’s telling us his own stories: one after the other. You could interrupt him, but you don’t.
I am feeling the anxiety of the group through my own anxiety: counter-transference. I feel that the group is distancing itself, through Gerard‘s all encompassing, manic intervention, from the suffering of real living, from the here and now, of a dismemberment produced by illness and death. As therapist, I have tried to stimulate the group‘s capacity for reflection with my intervention. The attempt failed.
Something happens later in the session in response to Gerard‘s imposition: a confrontation between him and Conchita. A power struggle that reflects exactly the position of the group with respect to Gerard‘s attempts at reconstruction. It is an attempt albeit a desperate one, through this verbal invasion, to avoid the destruction of the group. It is an attempt to reconstruct this fragmented group that expresses his frustration at its losses, it is a lost world that neither a God nor a dictator could make good. The group is trying to organize itself desperately before disaster ensues, as can be seen in this fragment:
Conchita: Time is dominating us.
Therapist: Wasn‘t it Gerard who was being dominating?
Conchita: He wants to, but everyone does what they want.
There is another attempt of invasion by Gerard. He wants to talk about the time he was the president but he can‘t: Conchita rebels and doesn‘t let him talk, although they end up talking over each other. It‘s a very real struggle. Gerard wants to talk but he is not allowed to. Thanks to the supervision of Dr. Folch, it is obvious to me that Gerard’s aim with his invasive tactics is the recovery of the group: but the group captures his manic defence and attacks with Conchita‘s intervention. After such harsh and destructive life experiences, only a manic defence can maintain group integrity. In this way death anxiety is annulled.
The Aim of Psychotherapy. The Role of the Psychotherapist.
It seems that death is something unspeakable: its burden and thoughts of it are devastating. As therapists, within group space, we should find time to talk about death and its qualities. Death is, after all, the real leading character here. Group members talk about “The black one”, “The grim reaper”, “The one with the scythe”, which is how they refer to death.
If we could verbalize death and talk about what we feel when faced with this irreversible fact, we could lighten the terrifying load that overwhelms thought and feeds our worst nightmares that even end up destroying us because they are overwhelming. If experienced as a process of regression (Folch et al., 2012) death would find a different place in the inner world of the group members and it would produce a greater level of tolerance and acceptance of the passing of time and the acceptance that time is irrecoverable.
No one kills us, unless of course we are murdered. We just die. There is no one who comes and seizes our lives: we just die. Simply and naturally, we die. Just as we are born. And this is the great mystery. There is something terrible that we deposit in death; something that makes it almost unspeakable. The collective imagination – and this is evident in the sessions – is filled with terrifying images that give death form. These images can help us to understand the experience within the group.
The group flees from Death, he who comes with a scythe in his hands, reaping away our lives, he who represents the most catastrophic of anxieties. This sensation is probably linked to the fact that we know nothing about it, and this leads us to the great mystery about death and the act of dying. But here, we are all equal, and there is no place we can hide from it.
The main aim of group psychotherapy should be that of developing an idea of death as a process of involution (Folch et al., 2012), which is a more appropriate representation of the real act of ceasing to exist, and one not so closely linked to the terrifying and persecutory idea of someone who comes to take what is ours.
The therapeutic goal should be to transform the experience of a terrible death that comes to cut down our lives (as in the painting by Denise Poncher: see Figure 2), into a death felt in a more peaceful and delicate way: death as a consequence of having lived in our transient state (as reflected in the work of Georges de La Tour: see Figure 3). The terrible death that comes to steal away our lives should give way to death as a result from living: a leaving off of life that connects us with our beginning.
Figure 2. Denise Poncher Before a Vision of Death (circa 1500). From the Chronique Scandaleuse, Malibu: J. Paul Getty Museum.
By talking and verbalising all the anxieties that death creates, we as therapists should be able to navigate – in each of our sessions – through a sea of reflection, highlighting the aspects of decay that ageing brings. If we are able to put a name to death and everything that we feel with respect to this event, we can also lighten the terrifying burden that overwhelms thought and which feeds our most destructive and paralysing fantasies. The following image (Figure 2) illustrates the terrifying, and persecutory idea of one who comes to take us what is ours. Horrific death with scythe in hand, coming to take us with him.
With a skull and a flame that burns away languidly, Georges de La Tour (Figure 3) demonstrates our transience in a more peaceful, delicate way, which is what we, as therapists, should seek to achieve with our patients, in order to create a space for words, for reflection and thought.
Figure 3. Penitent Magdalene (Magdalena with two candles) (1625–1650). Georges de La Tour. New York: Metropolitan Museum of Art.
Brotherhood. Solidarity. Vignette 3
I will continue by detailing what happened within the group at the session following the one I have referred to previously, in which there were so many absences. This fact triggered series of significant injuries among the group members. A completely different pattern emerged in this session. In it one can appreciate the importance of solidarity, accompaniment and a sort of family affection.
The group members began talking about their physical losses, about bodily injuries: Gerard talked about the holes in his lungs and his pleura and the biopsies the doctors carried out. He also talked about his prostate. Matilde spoke of the heaviness in her chest that prevents her from even hearing what people are saying.
Montse describes the prosthesis she wore between her back and chest that has now been removed. Trini talks about her loss of sight. Conchita defines herself as “completely deaf”. While the group is talking about body language, a certain kind of brotherhood occurs. There is a general complaint about the losses that the body suffers. The physical wounds allow a link to be formed between group members: they reveal a sense of brotherhood.
And during the session, almost half-way through a striking fact occurs that demonstrates the fragility of this elderly group: Aurelia begins to shake with intense tremors. I get up and go to her, and gently ask her what’s wrong, as she is prone to occasional microseizures. She opens her eyes and says “Nothing”, “It’s nothing”, “It’s already over”. When I go back to my seat, I feel that I’m in a group surrounded by death. I feel it intensely. Here everyone is sick; this is what the group is manifesting today.
At this point there is no discord. In the previous session we hurt each other, but in this one we are “going hand in hand”. The physical wounds put us in contact with other kinds of wounds that appeared in the previous session, but today we are with each other. We walk towards death but we are not alone: we have and experience a common destiny. We can go hand in hand as Trini says when talking to Genoveva about the next trip they will take (health permitting):
Trini: Last year I couldn’t go hiking. I can’t remember why!
Josep: You’ll go next time!
Trini: We’ll see!
Montse: Of course, yes, if we are in good health, we’ll go hand in hand.
Everything is said in a conciliatory tone with complicity. Words are said with a new meaning and at this point, the group changes its tone; people start talking about the sea. Gerard uses a successful metaphor about brotherhood that is being consolidated in the group today: he talks about a piece of land of about 7 or 8 km from the city of Ibiza, where he used to go with his family to have lunch. They used to cook paella. They made non-competitive contests: everybody tasted everyone else’s food to improve their own. They were all cooks and everyone learned how to make their food better. “We should do these kinds of things,” says Gerard, laughing, and he evokes his father as “the best paella chef”. They all talk together enthusiastically, “People love each other” says Montse. And I am surprised at the feelings that have arisen from the subject of the sea although still accompanied by other ambivalent aspects such as the dangers and the fears.
My psychotherapeutic intervention focuses on these of solidarity aspects and I stress this brother-hood experienced by the group that brings each of its members out of their solitude. We are alive and we are together.
The following image (Figure 4) may well be representative of what happened today in the group: we are all full of wounds, faults and shortcomings, but we are together. We are supportive of each other with a common, inexorable destiny. Our destination is a shared one. We know not what it is and we enter into it; there is no going back while still alive. Like the blind in the picture (Figure 4). This is an image that I visualize in my mind after listening to the group talking about their pains and before my intervention when I talk about the brotherhood that the group experiences; the feeling of having a shared fate.
Figure 4. The Parable of the Blind, P. Bruegel the Elder (16th century). The Naples Museum of Capodimonte. Italy.
Difficulties. More Defences. Vignette 4.
Death awakens enormous suffering and it also reveals the difficulty faced by therapists with respect to group defence strategies. Death comes suddenly, without warning. In an Assisted Living Facility, sometimes it also comes on a massive scale. It is excessive and those who remain alive are left dejected.
I remember fragments from a session that took place two days after four people who were already living in the centre died. All of them died on the same day. This fact in itself already produces a chill, and it is almost as if Breugel’s The Triumph of Death had come true.
The session began with a good, though defensive tone. After a while my own health was mentioned:
Montse: Are you better yet?
Therapist: I had the flu. I had fever and I didn’t feel well, but I‘m okay now.
Trini: Nothing is wrong. Fina: She‘s better.
Montse: You have to go through the whole process.
Blai: The strong remain, and the weak too! They’re not leaving, no (laughing) no, not everyone’s going away!
All the members laugh at Blai’s words. And then there is a long silence. No one refers to the four deaths. Nobody wants to talk about it. This fact highlights the difficulty the group has in verbalizing death. After Blai’s words, I say: “But some people have left, Blai; there are some who do leave: this week four people died here at the centre. Don‘t you think we can say that these people have gone?”
Again, no one shows any interest in talking about it, except Jan, who begins to relive the memory of one of the people who have died, and the group quickly shuts him up. No one is interested in talking about what caused the deaths of their four companions. It would appear that a pact of silence has been established.
Gerard starts talking in a delirious tone about the deaths of his sisters-in-law. He says in an almost comical way that he had four sisters-in-law who died more than 30 years ago. The group laughs enthusiastically. Blai begins to talk about Loba, a character whom he spoke about at the last session, which made everyone in the group laugh. The group now laughs again. Jan makes a new attempt to talk about one of the women that has died: Teresina.
The group does not let him: the members go on joking about Gerard’s four sisters-in-law. Josep appears confused: uncertain about who is dead and who is not.
And finally, in an almost desperate and masterly act of defence, Ferran makes an association between one of the people who have died and a crime that occur- red five years ago in the Garrotxa (a nearby region) in which Teresina‘s son-in-law was killed at his own restaurant.
And the daughter was that one who was living in Les Preses (a small town) whose husband was killed in La Vall del Bac (a small village). He was killed at his own restaurant. I used to go and eat there sometimes.
Then, the group starts talking about Teresina‘s son-in-law, who was murdered; stabbed several years ago by some of his workers at the restaurant in La Vall del Bac. All the members of the group are talking at once. There is some commotion. The group finally gives the floor to Ferran and he begins to talk, explaining the murder in detail and at length. He talks in an obsessive, manic and even aggressive way:
Blai: Those who killed him were already inside when he closed the door of the restaurant. They were inside!
Ferran: They had some balls! They knew each other! Employees! Come on! He took them on for work, and they killed him!
All this is said in a very angry tone. He‘s also scared.
Ferran: After cutting his throat, they went off. As if nothing had happened. After cutting his throat with two knives! They left him right there and went off! My God! They were cold-hearted!
He goes on in a very excited mood while explaining all of this. All the while gesticulating simultaneously with his hands, head and arms. The women in the group make faces of displeasure and short, emotional exclamations.
A major disturbance has been created.
According to Bion (1979), we are within the basic assumption of attack and escape. The group has already generated a distance to ‚our‘ nearby deaths, the deaths that occurred in the centre two days before. That is really why we feel so threatened. We can speak about the death of others, we can talk about hideous and gruesome murders, but when it happens outside, not here in our centre, not at home.
At a counter-transference level I am experiencing the restlessness of the group, which is struggling to flee from death. The group is fleeing from the reality that today is imposing itself in an overwhelming way. I try to take an inner look at what is happening and after reflecting, I wonder how I can help the group to name what is happening here and now, without it actually being me who does this. I question my right to take this initiative. How can I stimulate the group‘s ability to enter into emotional conflict and shock after the death of four people?
As a therapist, I try to push the group towards what is happening in our centre, and not outside, but all attempts come to nothing.
Therapist: We were talking about people who died at home and we have ended up talking about a tragic and violent death, about a man who has been murdered with a knife.
Now, interrupting me, Ferran acts out the scene with his arms and face. He goes into a monologue:
Ferran: Yes, now you…then, me…here… then… there…. damn you a knife…you and me again… there… there… now get him man… one, two, six…. and so on… it’s like they were getting their anger out. With a knife! But what the hell are we doing? We’re killing a man! And they didn’t see it like that, they didn’t see it.
Like the rest of the group, I am impressed. We are fascinated and enraptured by Ferran’s narrative. The violence of the events described keep us separate from the four deaths that have occurred here at home. The group becomes a spectator of death and not an actor; it is easier and we prefer to be seduced. The suffering created by this near and large-scale death is possibly too painful to talk about it. It is better to be a spectator than an actor. The group retreats, and escapes, because it is difficult to express what it is feeling when faced with such an overwhelming loss. It is better not to talk about it and keep these losses at arm’s length. Ferran takes up almost the entire session with this spectacular story of a crime that is so distant in time. Later, the group will talk about punishments, education and teachers, but not about the deaths. As a therapist I also remain trapped in this group escape; in this pact of silence.
My attempts at redirecting the group are in vain. Every time I mention the four dead, they ignore my words. The following fragment is taken from the last part of the session, when the session was almost at an end:
Therapist: Four people have died this week in our home, we have been talking about the killing of Teresina‘s son-in-law. Maybe the group thinks that with firmer attitudes (like those used by teachers before) this kind of thing could be avoided.
Cinta: This didn’t happen before.
Blai: Not so much. But evil has always been here and it always will be.
Jan: Perhaps there was more need before.
The group continues talking about teachers and education in order not to mention triumphant Death, who is too close by. The image up illustrates death as the group today has envisioned it; an enormous, devastating death, which has brought the group together in a pact of silence (Figure 5).
Figure 5. The Triumph of the Death by P. Bruegel (1562). Madrid: Prado Museum.
I would like to finish this work with the complete work of the painting I mentioned at the beginning. This is the triptych ‘The Garden of Earthly Delights’ by Hi- eronymus Bosch (15th century). It is an oil painting on wood with a central part and two side panels. (Figure 6).
Figure 6. The Garden of Earthly Delights, triptych opened. Hieronymus Bosch (15th century). Madrid: The Prado Museum.
I have already mentioned about how often the images of this work come to my mind when I work with this elderly group at the centre. Hell, which corresponds to the right side of the painting, makes me think about the constant dismemberment suffered by our group. It is an apocalyptic image that reminds me of the difficulty involved in processing the death anxieties of a group where death is present in such a significant and overwhelming way.
But not all is death and decay in the painting. The opened triptych presents Paradise on its left panel, where one can see a peculiar interpretation of the last day of Creation, with Adam and Eve. The source of life – something between a mineral and organic object – is in the middle of the lake. There is also the tree of life – an exotic dragon – and the tree symbolising good and evil – the palm tree, with the tempting snake wound around it. At first glance, the first part presents the viewer with a world filled with peace, but upon closer inspection, evidence about what is about to happen next is also revealed. There are already signs that are unrelated to peace. Paradise is interpreted as a prelude to sin, especially with respect to the representation of insects, reptiles and animals that devour each other.
In the central part, the carnal pleasures, madness and outrageous lasciviousness are represented (Gibson, 1993). Life is lived in a frenetic way and this is evident in the representation of the most basic instincts. All is sex and the pleasures of the flesh. Lust reigns in this oppressive and distressing space where madness seems to have gripped the world: both men and women are represented, black and white, nude, immersed in erotic plays, participating in heterosexual, homosexual and masturbatory scenes. Everything is laden with symbolism; each of the scenes that are part of the Garden of Earthly Delights could be carefully analysed, considering their symbolic wealth. It seems, however, that in the end, it is a positive and highly desirable world, full of happiness without pain, illness, or death. The passage of time is not represented; there are neither children nor old people. Nor is anyone working. Everyone is enjoying themselves.
The opposite happens in our group psychotherapy sessions. The group would like to immerse itself in a kind of collective madness in an attempt to avoid the anxiety that death produces. On the right side of the painting, condemnation to Hell is represented, where humans are doomed to an apotheosis and cruel world as a consequence of the sins committed and represented in the central part of the painting. Everything is laden with symbolism. Each one of the elements, each animal and each of the scenes have an important meaning; I will not go into detail here, due to the issue of scale. The aim of the painting seems to be a moralising one, as corresponds to medieval tradition.
What I find most interesting and remarkable is the structure of the painting; its symbolic frame: when the triptych is opened, its physical closure is in fact also symbolic as its contents reveals the beginning and the end of Man. The start on the left side – representing Genesis and Paradise – and the end on the right side, represented by Hell. Life and Death. One as a result of the other. The closed triptych shows yet another image: the creation of the world.
A globe with Earth inside a transparent sphere is shown, which could symbolise the fragility of the universe, of life itself (Figure 7).
Figure 7. The Garden of Earthly Delights, triptych closed. Hieronymus Bosch (15th century). Madrid: The Prado Museum.
Is this the image of death? With the triptych closed, we see plant and mineral images and a small God-like figure on the left. There are no people or animals. The painting is colourless and there are only shades of grey, black and white. A world without sun or moon. A world in which there is no animal or human life. A representation of the beginning of life, which curiously, on contemplation, leads one to think of death. By opening Bosch’s The Creation of the World, a symbolic closure occurs, as its content is the beginning and the end of Man.
According to Bion, the therapist taking into account the function of the unconscious should help to develop scientific curiosity for the inner object. Learning and knowing implies incorporating reality. Only with the capacity to enter into an emotional conflict and experiencing a commotion, will we be able to extract a meaning that we can give a name to. But there is something that we cannot know: the dimension of the infinite. We will never know everything. I believe that in the act of dying, in the act of ‘ceasing to be’ this evidence is revealed. And precisely this is what our group is confronted with in each one of our sessions. Great doses of humility are required as a therapist.
I cannot conclude without expressing my sincere thanks to all the colleagues who were and are still involved in the research project into old age, who I have been working with and supervising since January 2012. Without them it would be very difficult to move ahead in these seas of uncertainty. I have very special memories of Dr. Pere Folch, who, with his words of wisdom enlightened me, and who passed away on 11 December 2013.
Raquel Vidal Arandes
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