THE INTEGRATION OF INTERPERSONAL AND EXISTENTIAL APPROACHES IN GROUP PSYCHOTHERAPY

1. 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

2. One Version of Contemporary Psychotherapy

3. 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 Healing Context

4. 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 model’s 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)

5. EXISTENTIAL PSYCHOTHERAPY “A dynamic approach to therapy which focuses on concerns that are rooted in the individual’s 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

6. 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 individual’s choice to misconstrue and misconstruct (Yalom and Leszcz,2005)

7. GROUP PSYCHOTHERAPY AND EXISTENTIAL CONFRONTATION • Range of misaligned, inauthentic modes of relating – illuminated in social microcosm of the group’s here and now interaction • Therapist’s presence and relatedness are key • Therapist’s investment of attention, intention, connection • Therapist as participant and observer

8. 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 one’s past and present choices, choices made with clarity and deliberation as well as choices clouded by self-deception and distraction,” (Mitchell, 1989)

9. 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 one’s mental life, but one can choose to work in good faith • Personal ownership of the active and wilful dedication to one’s relational matrix, is a crucial prerequisite to authentic engagement and a broadening of one’s interpersonal repertoire

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

11. 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?

12. 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)

13. EXISTENTIAL CONCERNS C. FREEDOM and RESPONSIBILITY • “Condemned to freedom” (Sartre) • Live time or kill time • Responsibility and authorship for one’s 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, don’t defer

14. 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 one’s 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)

15. Interpersonal Skill Development 101

16. 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

17. 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)

18. 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

19. 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

20. “Do what I say and you’ll be okay.” DOMINANT HOSTILE-DOMINANT FRIENDLY-DOMINANT “Your efforts are disappointing: I’ll have to do it myself.” “I’m clever and will dazzle you with my talents.” HOSTILE FRIENDLY “You annoy me: stay away from me.” “I like you and want to help you.” FRIENDLY-SUBMISSIVE HOSTILE-SUBMISSIVE “You’re wonderful: I trust you completely.” “You’re famous: fix me (if you can).” SUBMISSIVE “I’ll do anything you say: just take care of me.” Octant Complementary “Pulls” of Kiesler’s Interpersonal Circle(1996)

21. The Interpersonal Circle

22. THE IMPACT MESSAGE (Kiesler, 1996) • Identifying and metabolizing the patient’s 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)

23. FOUR DOMAINS OF THE MALADAPTIVETRANSACTION CYCLE PatientTherapist Overt Interpersonal BehaviorReaction (misconstruction) (complementary or non complementary) Covert Phenomenological ExperienceImpact Message (misconstrual and core beliefs) (examined and metabolized) Therapist must examine : - direct feelings induced - perceived evoking message - behavioral responses - covert mental processes

24. 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 patient’s part

25. 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 • Patient’s accumulating awareness that challenges obstructions

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. THE CORRECTIVE EMOTIONAL EXPERIENCE • The group is an unnatural place for natural relationships, not a natural place for unnatural relationships • Genuine and authentic • Illuminationand 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)

36. 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 abuser’s state of mind. (Fonagy and Bateman, 2006)

37. 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

38. 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

39. 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

40. 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

41. INTERPERSONAL FEEDBACK(Morran et al 1998; Yalom and Leszcz, 2005) • Sender takes a self-disclosure risk • Explore sender’s 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

42. 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

43. 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