THE INTEGRATION OF INTERPERSONAL AND EXISTENTIAL APPROACHES IN GROUP PSYCHOTHERAPY

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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

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One Version of Contemporary Psychotherapy
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EVOLUTION OF PSYCHOTHERAPY

• Classical ? ???Contemporary
• Conflicts ego ? Deficits self
• Drives instincts ? Attachment relationships
• Guilty man ? Tragic man
• One-person psychology ? Two-person psychology
• Intrapsychic ? Intersubjectivity
• Therapist abstinence ? Therapist engagement
• Dispassionate guide ? Participant observer
• Opaque ? Presence
• Interpretation understanding ? Relationship
  empathy

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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)

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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

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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)

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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

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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)

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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

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EXISTENTIAL ISSUES

• A. DEATH
• B. ISOLATION
• C. FREEDOM and RESPONSIBILITY
• D. MEANING
• not discrete, but interwoven
• guide the psychotherapeutic endeavor

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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?

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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)

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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

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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)

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Interpersonal Skill Development 101
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THE INTERPERSONAL MODEL OF GROUPPSYCHOTHERAPY
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

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THE INTERPERSONAL MODEL OF GROUPPSYCHOTHERAPY
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)

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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

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THE INTERPERSONAL MODEL OF GROUPPSYCHOTHERAPY
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

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Do what I say and youll be okay.
DOMINANT
FRIENDLY-DOMINANT
HOSTILE-DOMINANT
Your efforts are disappointing Ill have to do
it myself.
Im clever and will dazzle you with my talents.
FRIENDLY
HOSTILE
I like you and want to help you.
You annoy me stay away from me.
FRIENDLY-SUBMISSIVE
HOSTILE-SUBMISSIVE
Youre wonderful I trust you completely.
Youre famous fix me (if you can).
SUBMISSIVE
Ill do anything you say just take care of me.
Octant Complementary Pulls of Kieslers
Interpersonal Circle(1996)
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The Interpersonal Circle
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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 cognitive- interpersonal 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)

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FOUR DOMAINS OF THE MALADAPTIVETRANSACTION CYCLE

• Patient Therapist
• Overt
• Interpersonal
• Behavior Reaction
• (misconstruction) (complementary
  or non complementary)
• Covert
• Phenomenological Experience Impact
  Message
• (misconstrual and core beliefs) (examined and
  metabolized)
• Therapist must examine - direct feelings
  induced - perceived evoking message
• - behavioral responses - covert mental
  processes

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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
• Pathogenic belief disconfirmation
• ? ??access to genetic material, previously covert
• ? Progressive emboldenment on the patients part

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PLAN FORMULATION MODEL(Weiss Sampson et al,
1986, Weiss, 1993)

• I GOALS
• Developmental tasks, relatedness, self, growth
• II OBSTRUCTIONS
• Pathogenic beliefs, emerging from early life
• Shaped by danger/costs of goal attainment to self
  or others
• III TESTS
• 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
• IV INSIGHT
• Patients accumulating awareness that challenges
  obstructions

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

• Highlights and addresses misconstrual-misconstruct
  ion 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 gt 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

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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

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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

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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

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TREATMENT CONSTRUCTS FOR THE GROUP THERAPIST

• Repeat or repair confirm or disconfirm
• Insight and experience linked
  Corrective Emotional Experience
• Experience near ? "hot" processing or,
• Experience far ?? "cold" processing
• 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
  Interpersonal Learning
• Cohesion and therapeutic alliance are
  prerequisites

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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

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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

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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 here- and-now emotional life
• It will feel unnatural and prone to regressive
  avoidance

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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

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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)

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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)

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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

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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

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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

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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

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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 gt 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

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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

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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