THE INTEGRATION OF INTERPERSONAL AND EXISTENTIAL APPROACHES IN GROUP PSYCHOTHERAPY

Northern California Group Psychotherapy Society November 18, 2006

Molyn Leszcz, MD, FRCPC Psychiatrist-in-Chief Mount Sinai Hospital Associate Professor and Head, Group Psychotherapy University of Toronto, Department of Psychiatry

One Version of Contemporary Psychotherapy

EVOLUTION OF PSYCHOTHERAPY
Classical
Conflicts & ego Drives & instincts Guilty man One-person psychology Intrapsychic Therapist abstinence Dispassionate guide Opaque Interpretation & understanding

Contemporary
Deficits & self Attachment & relationships Tragic man Two-person psychology Intersubjectivity Therapist engagement Participant observer Presence Relationship & empathy

Healing Context

PSYCHOTHERAPY INTEGRATION

Multiple perceptions of therapeutic truth Each model, by its own definition ignores a universe of phenomena that are important to the patient, but that function outside of that models framework (Lazare, 1993)

Common Factors similar core mechanisms, regardless of conceptual frame (Frank)

Technical Eclecticism multimodal (Lazarus, Beutler) Theoretical Integration overarching theory that promotes seamless integration (Wachtel)
Therapists should realize that specific ingredients are necessary but active only insofar as they are components of a larger healing context of therapy. It is the meaning that the client gives to the experience of therapy that is important. (Messer and Wampold, 2002)

EXISTENTIAL PSYCHOTHERAPY
A dynamic approach to therapy which focuses on concerns that are rooted in the individuals existence. (Yalom, 1980)
Fundamental anxieties of existence and being Boundary experiences: jarring awareness of limits in life Therapy facilitates confrontation and engagement Counters avoidance and withdrawal Authenticity and presence Centrality of self: actualization v.s. constriction

Self and transcendence

GROUP PSYCHOTHERAPY AND EXISTENTIAL CONFRONTATION

Relationships as genuine and intimate self: self encounters not subject-object transactions utilized for:
shielding maintenance of grandiosity avoidance of isolation: fusion or surrender managing, not experiencing externalizing and blaming compulsive pseudoengagement/pseudomeaning entrapment to avoid anxiety of freedom, meaninglessness and underlying groundlessness, or death limits of relatedness/fundamental isolation and responsibility for self unbridgeable each individuals choice to misconstrue and misconstruct (Yalom and Leszcz,2005)

GROUP PSYCHOTHERAPY AND EXISTENTIAL CONFRONTATION

Range of misaligned, inauthentic modes of relating illuminated in social microcosm of the groups here and now interaction

Therapists presence and relatedness are key

Therapists investment of attention, intention, connection Therapist as participant and observer

GROUP PSYCHOTHERAPY AND EXISTENTIAL CONFRONTATION

Bad faith to explain only the why of behavior without taking responsibility for the what The self is created from meaning assigned to experience . . But the meaning of the experience is not a given; it is composed, created, designed. The self is not produced by motives and causes, there is also the creative will of the individual. Clinical work which does not take this into account (can) become an intellectual exercise in explanation and rationalization, rather than providing increased responsibility for ones past and present choices, choices made with clarity and deliberation as well as choices clouded by self-deception and distraction, (Mitchell, 1989)

GROUP PSYCHOTHERAPY AND EXISTENTIAL CONFRONTATION

Yet all cannot be attributed to will only, or therapy becomes disembodied of meaning, and an exercise in moral confirmation, blaming and haranguing One cannot will total access to ones mental life, but one can choose to work in good faith Personal ownership of the active and wilful dedication to ones relational matrix, is a crucial prerequisite to authentic engagement and a broadening of ones interpersonal repertoire

EXISTENTIAL ISSUES

A.
B. C. D.

DEATH
ISOLATION FREEDOM and RESPONSIBILITY MEANING
not discrete, but interwoven guide the psychotherapeutic endeavor

EXISTENTIAL ISSUES
A. DEATH

Phobic avoidance and dread

Act of death vs. idea of death Death vitalizes life

Death as a co-therapist
Alive to the moment Detoxification of death by confrontation with it Meter is running Pivotal and grounding question: Will I die?

EXISTENTIAL ISSUES
B. ISOLATION
Fundamental aloneness and unbridgeable responsibility for self Human connection and authentic human encounter Here and now illumination Realignment of relatedness

Genuine and intimate self: self encounters

Not subject - object transaction, or parallel solitudes Maximal engagement for maximal time Avoidance of isolation by fusion or surrender

Life preserving value of social support and social integration (Reynolds et al 2000)

EXISTENTIAL CONCERNS
C. FREEDOM and RESPONSIBILITY

Condemned to freedom (Sartre) Live time or kill time Responsibility and authorship for ones life Identify wish and uncover will Existential guilt of failing to be true to self Attitude with which life is faced is ours to determine (Frankl) Activate, dont defer

EXISTENTIAL CONCERNS
D. MEANING
Repriorization of life values

Self-image: core self beneath manifest attributes

Trivialize the trivial Tragedy that only illness awakens us Entrapment to avoid anxiety Attending to self can transcend the self Meaning must be determined in ones own terms Altruism: extract meaning from tragedy

Life projects - to engage life, not immortality

The why precedes the how: post-traumatic growth possible Social cognitive processing (Schmidt and Andrykowski,2004)

Interpersonal Skill Development 101

THE INTERPERSONAL MODEL OF GROUP PSYCHOTHERAPY: THEORETICAL CONSTRUCTS

The central imperative of interpersonal attachment: maintenance of self within context of relationships (Sullivan, 1953) Affect attunement (Stern, 1985) and the reflected appraisals of significant others shape the individual in addition to innate temperament and biological predisposition Psychological disturbance reflects interpersonal disturbance

THE INTERPERSONAL MODEL OF GROUP PSYCHOTHERAPY: THEORETICAL CONSTRUCTS

Interpersonal disturbance is manifest in characteristic recurrent, disturbed interpersonal communication including verbal, nonverbal and paraverbal communication Characterological and ego-syntonic, hence patient blind spots Maladaptively rigid bid for self-confirmation or security Interpersonal disturbance is viewed as a symptom, not judged

The contemporary interpersonal world is a window to the intrapsychic world composed of internalized past relational experiences (Basch)

THE INTERPERSONAL MODEL OF GROUP PSYCHOTHERAPY: THEORETICAL CONSTRUCTS

Cognitive-interpersonal schema misconstrual and misconstruction (Strupp & Binder, 1984) pathogenic beliefs (Weiss, 1993); unbidden cognitions and beliefs that generate contingencies, actions and strategies (Safran & Segal, 1990)

Program for maintaining relatedness - now outdated

Parataxic distortions and selective inattention Negative impact on cognitive-emotional development

THE INTERPERSONAL MODEL OF GROUP PSYCHOTHERAPY: THEORETICAL CONSTRUCTS

Circular causality: interpersonal recapitulations - the attempted solution becomes the problem (Kiesler, 1996) The Maladaptive Transaction Cycle - the unbroken causal loop and personal authorship

Interpersonal circle construction is predictive: axes of power and affiliation

Potential for self-fulfilling or self-defeating sequence

Broaden the interpersonal repertoire

Peer relationships are essential and shaping influences

Do what I say and youll be okay.

DOMINANT

HOSTILE-DOMINANT Your efforts are disappointing: Ill have to do it myself. HOSTILE You annoy me: stay away from me. HOSTILE-SUBMISSIVE

FRIENDLY-DOMINANT Im clever and will dazzle you with my talents. FRIENDLY I like you and want to help you. FRIENDLY-SUBMISSIVE Youre wonderful: I trust you completely. SUBMISSIVE

Youre famous: fix me (if you can).

Ill do anything you say: just take care of me.

Octant Complementary Pulls of Kieslers Interpersonal Circle(1996)

The Interpersonal Circle

THE IMPACT MESSAGE (Kiesler, 1996)

Identifying and metabolizing the patients interpersonal impact message Alert to what we as therapists bring to the mix, regarding our cognitiveinterpersonal schema Consider: Your experience with the patient Identify: Direct feelings - when I am with this person he (she) makes me feel Action tendencies - when I am with this person he (she) makes me feel that I want to Perceived evoking messages - when I am with this person he (she) wants me to feel and behave Fantasies - sometimes when I am with this person it seems to me as though (image or metaphor)

FOUR DOMAINS OF THE MALADAPTIVE TRANSACTION CYCLE

Patient Overt Interpersonal Behavior
(misconstruction)

Therapist

Reaction
(complementary or non complementary)

Covert Phenomenological Experience

(misconstrual and core beliefs)

Impact Message
(examined and metabolized)

Therapist must examine : - direct feelings induced - perceived evoking message - behavioral responses - covert mental processes

THE PLAN FORMULATION MODEL

(Weiss, 1993)

The Plan is the manner in which the individual will work in psychotherapy to disconfirm PBs, overcome obstructions and achieve goals. Misconstrual -misconstruction sequence enacted Treatment is either part of the problem or part of the solution Plan-congruent interventions, regardless of transference focus produces:
self-awareness access to affect and self-reference access to genetic material, previously covert Progressive emboldenment on the patients part

Pathogenic belief disconfirmation:

PLAN FORMULATION MODEL

(Weiss & Sampson et al, 1986, Weiss, 1993)

GOALS

Developmental tasks, relatedness, self, growth Pathogenic beliefs, emerging from early life Shaped by danger/costs of goal attainment to self or others Displacement of past onto present or, inversion of passive into active PB disconfirmation sought within therapy and other relationships Driven by hopefulness, yet dreading confirmation Both insight and relational experience matter Patients accumulating awareness that challenges obstructions

II OBSTRUCTIONS

III TESTS

IV INSIGHT

COGNITIVE BEHAVIORAL ANALYSIS SYSTEM OF PSYCHOTHERAPY (Keller et al,2000; McCullough, 2000; Klein
et al 2004)

Highlights and addresses misconstrual-misconstruction sequence Highly effective in treatment of chronic depression (Keller et al, 2000) Identifies core deficits in cognitive-emotional development, as the root and/or the result of chronic depression Early life deprivation, neglect, absence results in: chronic feelings of worthlessness chronic feelings of helplessness in Piagetian terms, stuck at preoperational level of cognitive development
affects are timeless/endless lack of causal understanding in emotional world concretistic > abstract lack of if this . . . then that understanding in interpersonal sequence lack of empathy to experience of others passivity, lack of initiative, erosion of will rigidity

COGNITIVE BEHAVIORAL ANALYSIS SYSTEM OF PSYCHOTHERAPY (Keller at al, 2000; McCullough, 2000; Klein et al
2004)

Requires active focus on interpersonal and relational patterns Both experience and understanding in treatment focus on negative reinforcement - i.e. extinguishing maladaptive behavior and recruitment of destructive interpersonal reactions Treatment repairs or repeats role of interpersonal discrimination learning Disciplined, but personal therapeutic involvement required

COGNITIVE BEHAVIORAL ANALYSIS SYSTEM OF PSYCHOTHERAPY (McCullough, 2000)

Aim for development of formal operations (Piaget)

cause and effect understanding ownership of initiative awareness of impact empathy discrimination of past from present emboldenment

Model not yet tested in group setting, but treatment formulation resonates with and deepens the interpersonal approach

TREATMENT CONSTRUCTS FOR THE GROUP THERAPIST (Yalom and Leszcz, 2005)

The focus of clinical study is the here-and-now interpersonal interaction and the patient's phenomenology The Here-And-Now Interpersonal recapitulation driven by cognitive-interpersonal schema and pathogenic beliefs The Group as Social Microcosm Hooking-unhooking phenomenon - recruitment of predictable interpersonal responses Impact message - pulls a restricted response Interpersonal markers of the patient Transference/countertransference illumination through the therapist's function as participant-observer Group provides multiple interactional opportunities and peer transferences Complementarity = an interpersonal behavioral and its most probable interpersonal response Reciprocity regarding power axis Concordance regarding affiliation axis

TREATMENT CONSTRUCTS FOR THE GROUP THERAPIST

Repeat or repair: confirm or disconfirm Insight and experience linked Experience near "hot" processing or, Experience far "cold" processing
Corrective Emotional Experience

Collaborative feedback and exploration to deepen awareness of schema: explore the phenomenology of the contemporary interaction
Role of metacommunication - communication about communication Understanding of schema is always evolving - dynamic Broaden the interpersonal behavior repertoire Cohesion and therapeutic alliance are prerequisites
Interpersonal Learning

THE GROUP WORKING IN THE HERE AND NOW

1.

Social Microcosm

In-vivo

Being, not just describing or reporting

Limits of dyadic treatment Face validity of the experience-near exploration

THE GROUP WORKING IN THE HERE AND NOW

2. The Here and Now Alive to the moment and immediacy: intimate engagement - likely to be resisted

The then and there "What does this have to do with why I'm coming here?

Affective stimulation and cognitive integration, in balance

Stimulate emotional experience and then foster self-reflection Content and process

Track analogues to experience of outside relationships

Track phenomenological experience of here-and-now relatedness

THE HERE AND NOW

Horizontal vs. vertical disclosure

Centripetal focus: each person integrally involved at each moment; not a turn-taking model Plunge the group into exploration of each member's hereand-now emotional life It will feel unnatural and prone to regressive avoidance

THE HERE AND NOW

Think here-and-now 4 vectors Maintenance (bridging) vs. mutative interventions (feedback) Levels of inference, choice point analysis Dynamic insight is depth indeed and essential to interpersonal change Linear causality, emphasizing the past is delimiting and may invite stagnation and blaming, diminishing personal responsibility

Collaborative exploration of circular causality

Once illuminated opportunities for repair ensue

THE CORRECTIVE EMOTIONAL EXPERIENCE

The group is an unnatural place for natural relationships, not a natural place for unnatural relationships Genuine and authentic Illumination and disconfirmation - both by understanding and experience Endorsing new behaviors and risks Empathic resonance: affect attunement

Activation of attachment thru the exploration of past, current, member-member and member to therapist relatedness. (Fonagy and Bateman, 2006)

THE CORRECTIVE EMOTIONAL EXPERIENCE

Risk of role lock Therapist as advocate, even for the antagonist Hooking-unhooking: - buy time to reflect: don't bite at the bait

No behavior or interaction is meaningless - assume it is either schema confirming or disconfirming The cognitive-interpersonal schema develops honestly through life experience - it served an adaptive purpose once Mentalization the capacity to think about the state of mind (feeling and intentionality) of others requires the experience of being held in mind developmentally or psychotherapeutically. Therapy counters the inhibition of mentalization resulting from abuse/deprivation and the avoidance of thinking about the abusers state of mind. (Fonagy and Bateman, 2006)

THERAPEUTIC METACOMMUNICATION AND FEEDBACK

Prerequisite of therapeutic alliance and group cohesion

Interrupts maladaptive transaction cycle and promotes opportunity for change and not recapitulation
Potentiates healthy connection with accurate empathy Underscores the joint creation of the relationship Encourages overt rather than covert communication May permit tolerance of personal difference once clearly stated Models authentic engagement and responsibility, without collusion Facilitates noncomplementary and growth producing interpersonal response

PROPOSITIONS FOR METACOMMUNICATION

(Kiesler, 1996)

Communication about communication - Processing Process of unhooking begins with identification of the impact message Once acknowledged, may interrupt the complementary response Speak directly about the communication process and transaction Choose what MTC quadrants to emphasize, and in what sequence

PROPOSITIONS FOR METACOMMUNICATION

(Kiesler, 1996)

Collaboratively explore the presence of the identified pattern to refine or corroborate understanding Use metaphors, if it is helpful to reduce intensity Reduce incubation period prior to feedback Seek every opportunity to bring focus back to the process of interaction in the here-and-now

PROPOSITIONS FOR METACOMMUNICATION

(Kiesler, 1996)

Provide feedback in challenging but supportive fashion, from position of lower affective intensity, rather than greater intensity Manifest positive regard, blending tact with authenticity Illuminate, not punish Acknowledge joint creation of the transaction Balance positive with negative feedback: lower the stakes Identify specifically what triggers negative interpersonal recapitulations, describing overt behavior and exploring covert meaning and beliefs

INTERPERSONAL FEEDBACK
(Morran et al 1998; Yalom and Leszcz, 2005)

Sender takes a self-disclosure risk Explore senders experience of feedback Nonjudgmental nor inflammatory well paced; positive preceded negative Focus on observable behavior in H & N > highly inferential Invitation for desired behavior as opposed only to rebuke link to goals of therapy Encourages the sender's responsibility for change without coercion Mutative impact on contemporary relationships, rather than highly inferential genetic reconstructions Genetic material follows rather than precedes

THERAPIST TRANSPARENCY AND DISCLOSURE

Well processed and metabolized Distinguish what is induced by the patient from the therapist's contribution - i.e. subjective and objective countertransferences

Determine the objective of the therapist's disclosure

Transparency is a tool, not an end in itself Comprehensive exposition of reactions to the here-and-now, ahistorical Find palatable ways to say unpalatable things

THERAPIST TRANSPARENCY AND DISCLOSURE

Risk of damage to the treatment with unchecked therapist hostility Essential modelling and norm setting

Too extreme a position regarding transparency, in either direction constricts efficacy

Protect the frame of treatment Alert to timing and stage of treatment Mirroring of growth and communicative matching