Artículos de Psicoterapia Integrativa

Abstract

   This article is the Keynote Address given at the 4th International Integrative Psychotherapy Association Conference, April 17, 2009. In speaking to the conference theme of “Acute Trauma, Cumulative Neglect, and Chronic Stress” the article describes some of the principles of Relational Group Psychotherapy. The theory of methods is based on the concept that the healing of trauma, neglect and stress occurs through a contactful therapeutic relationship. Relational group psychotherapy draws from several developments in group therapy, particularly the cybernetic feedback and other-centered models. It emphasizes the healing power of relationships between group members and the importance of phenomenological inquiry, affective attunement, identification, and relational-needs. The leader’s tasks are to stimulate the flow of contactful dialogue and to teach about human needs and healthy relationships.

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The healing of stress, neglect and trauma occurs through a contactful therapeutic relationship. This concept is based on the Integrative Psychotherapy theory of methods. By “contactful” we mean the capacity to be attuned to another person’s affect, relational-needs, rhythm, cognition, and developmental level. It also means to be respectfully present, authentic and congruent. By “therapeutic relationship” we mean the skill, commitment, intentionality and ethics of a professional psychotherapist.

The healing of stress and trauma may also occur through the multiple relationships in an effective group psychotherapy where the group members are involved and attuned to each other’s affect, rhythm, relational-needs, cognition, and developmental age of shame, neglect or trauma. Such involvement also includes each member’s commitment to honesty, authenticity and the integrity of the group’s therapeutic process.

People who have been affected by cumulative neglect, acute trauma or chronic stress require relationships that provide respectful inquiry into the person’s experience as well as an interpersonal involvement that provides consistency and dependability through acknowledgement, validation and normalization. It is the interpersonal involvement that heals. Trauma may be the result of acute events such as physical or sexual abuse, war or natural disaster, but it may also be the result of mental abuse that is caused by prolonged ridicule and criticism. Stress is often the result of living with prolonged shame, the accumulation of neglect, and unresolved trauma. Each of these events threatens the emotional and cognitive stability as well as the physical security of a person.

With acute trauma, cumulative neglect and chronic stress there is an increased need for protection, nurturing, empathy and understanding. When these needs are unmet people will develop self-protective strategies to maintain some mental and physical stability and a semblance of relationship. Such strategies include forming Script Beliefs about self, others and the quality of life, disavowing affect, desensitizing physiologically, dissociating from the sense of self, or distancing in relationship with others. When used habitually over time, these strategies interrupt the person’s ability to be contactful both internally with self and externally with others.

Trauma and chronic stress often remain as fixated experiences because the important people in a person’s life failed to provide the necessary restorative and nurturing functions. When an experience remains traumatizing it is often the result of a failure of a number of people to provide a protective, understanding and healing relationship. These failures may not only be by parents and may also include teachers, other relatives, siblings, and other children. Often an extended family, or even a whole community, is needed to provide the healing of trauma. Full interpersonal contact and honest communication between people is the means by which trauma and stress can be resolved.

It is in the quality of contact between people -- a series of authentic and sensitive encounters -- that the full awareness of both one’s self and the other is possible.

Models of Group Psychotherapy:

It is beyond the scope of this Keynote Address to cover a detailed history of the contributions of various models of group psychotherapy; however, I would like to describe three models of Group psychotherapy that have influenced my professional practice. They may be described as Therapy-by-the-Group, Therapy-by-Interpretation, and Therapy-in-the-Group.

Influence from each of these forms of group therapy have led to the development of an Integrative Psychotherapy model of Therapy-through-the-Group Process; a therapy that emphasizes the importance of human relationships and our interdependence on each other. The healing of stress, cumulative neglect and trauma is possible with contactful, caring relationships that attend to each person’s phenomenological experience and relational-needs.

In the 1930’s Alcoholics Anonymous (AA) began as a leaderless group. AA is based on the theory that alcoholism is a disease and individuals need the support of the group in order to stop drinking. The methods of the group are shaped by the Twelve Step program; every aspect of the group is determined by one of the twelve steps. Members are encouraged to tell their story, often over and over again. AA emphasizes honesty and responsibility as important elements in an individual’s rehabilitation.

In 1945, non-directive Group Therapy was developed at the University of Chicago by Carl Rogers and Bob Neville to treat War Neurosis. This form of group therapy emphasized a democratic process of equality and the encouragement of group members to share their traumatic stories and feelings with each other. By telling each other their stories over and over again, while receiving an empathetic response, the traumas of war were healed. The leader’s role is to model empathy, congruence, and unconditional positive regard for group members. There is no interpretation from the leader. The therapy in a non-directive group is not determined by a theory of motivation, personality or psychopathology but by the idea that people need to be authentic with each other about their emotional experiences.

Non-Directive groups and Alcoholics Anonymous groups represent what we call Therapy-by-the-Group. They are very different from the Psychoanalytic group therapies that emphasize the importance of the therapist’s interpretation. Several types of Psychoanalytic Groups began in the 1950’s under the influence of the Tavistock Clinic in England. The analyst’s task is to interpret group members’ behavior according to psychoanalytic theorists, including Sigmund Freud and Melanie Klein. Group members are encouraged to talk to each other and, in the course of the group’s discussion, each member’s childhood transferences and psychopathology are be revealed in their behavior. The leader does not speak until the end when he or she may make authoritative interpretations of group members’ pathological motivations for their behavior. For example, interpretations of an individual’s behavior might be attributed to unresolved aggression, envy, sexual attraction or infantile transference. In such Psychoanalytic groups, the authority of theory appears to be more important than the group member’s phenomenological experience. The leader’s interpretations are often shaming and provoke people to either withdraw or conform.

The 1960’s were a rich time of development in group therapy. Three trends emerged. Eric Berne made uses of a modified Psychoanalytic group to analyze group member’s transactions in order to determine which were transferential and which were not transferential. He was primarily focused on the transferences between group members that resulted in psychological games and reinforced their Life Script. He was active intermittently during the group’s discussions by making interpretations and explanations during the process rather than waiting till the end as in most psychoanalytic groups. His methods included explanation and interpretation about the theory of ego states and the rules of transactions, games and scripts. He attempted to create a sense of equality by engaging group members in making contracts for behavioral change. Although Berne did not make psychoanalytic interpretations about an individual’s pathological motivations, -- he focused instead on people’s interactions with each other -- both Berne’s Transactional Analysis groups and the Psychoanalytic Groups can be seen as a model of Therapy-through-Interpretation.

Also during the 1960’s Fritz Perls developed the concept of Therapy-In-the-Group. In these groups the psychotherapist did individual psychotherapy within the group while group members observed the individual therapy. Group members participated both vicariously and through their supportive statements at the end of the work. The psychotherapist was highly directive of the individual’s psychotherapy by encouraging the client to do psychological experiments, to be expressive, and to explore unfinished emotional experiences from the past. The theory is based on the concept of interruptions to contact: confluence, retroflection, projection, and introjection. Perl’s Gestalt Therapy Groups pioneered the concept of Therapy–in-the-Group and had a large influence on how Transactional Analysis and other forms of group therapy were conducted after the 1970’s.

The third trend of the 1960’s was the Encounter Groups. These groups began as a form of human relations training. The theory was based on a Cybernetic Model that we all affect each other in a myriad of ways, illustrated by the concept that the behavior of one person in the group is a direct influence on the behavior of the other people in the group. We are all constantly influencing each other. Encounter groups focused on various group members describing the behavior of each of the other group members and how that behavior affected them. Each member in the group was encouraged to give feedback to other group members and to be highly confrontative, even aggressive, in describing the others’ behavior. Direct confrontation was seen as a form of authenticity. Both an individual’s behavior and their lack of emotional expression were seen as his or her “problem”. The theory is based on the idea that people are often out of touch with themselves and needed an intense encounter with others in order to become authentic. Unfortunately, the lack of respect that often occurred and a heavy focus on behavior change made these groups shaming and traumatizing to some participants.

By the 1990’s there were a number of therapists experimenting with different forms of group psychotherapy. Many Group Psychotherapists were influenced in some way by these previous models. I too was influenced and stimulated to develop a form of group psychotherapy that was truly relational and co-constructive by making full use of the therapeutic potential in the group’s process with each other.

Today I will describe just two trends in Group Process and suggest how we might integrate the two to form a group psychotherapy that is effective in preventing stress and healing the wounds of trauma and neglect. The two trends in Relational Group are the “cybernetic feedback” model and the “other-centered” model.

Many current psychotherapy groups make use of a cybernetic feedback model of group interaction. Although such a model is interpersonal, it stresses the view-point of the speaker, emphasizing one person’s perspective as more significant than listening to and learning the other person’s perspective. For example, the speaker may say to another, “You are angry and withdrawn”. A pronouncement is made and the other is expected to respond. The focus is on each member’s perception and interpretation of other group member’s behaviors. The feedback is an expression of the speaker’s perspective whether or not it accurately describes the other person. Authenticity is defined as speaking in congruence with one’s own interpretation of the other’s behavior. The purpose of the group is to influence each other’s behavior and the message is, “This is how you affect me”.

Theoretically the therapy in the cybernetic model is in the continuous feedback of one member to another. However, a group that relies only on this mode of functioning often becomes shaming to many participants and invites either compliance or withdrawal. When used exclusively, this model of group psychotherapy may increase people’s stress, shame or a sense of being misunderstood within the group.

In contrast, an Other-Centered psychotherapy group places its focus on the other’s phenomenological experience and how each person’s subjective experience is manifested in behavior. In an Other-Centered group one’s personal perspective and interpretation is seen as inadequate in understanding the other person. Therefore, there is an emphasis on attunement with the other’s inner experience -- a resonance with their affect, perspective, and how they make meaning. It is based on the assumption that I know nothing about the other, that my observation and interpretation are not enough to understand them. One of the purposes of an Other-Centered group is to learn to see the other as he or she sees him or herself. Careful listening and inquiring are seen as essential to know the other. Empathy and attunement to the other’s affect, rhythm, and cognition is important. When people experience being truly known, without ridicule, their stress level decreases and they can more freely express themselves.

When using a Relational Group Process in Integrative Psychotherapy, we combine the best of both the Cybernetic and Other-Centered modes of working. The group members attend to each person’s phenomenological experience and provide respectful feedback. The therapy is through the relational process of each member being fully involved with each other member. When group members are attuned to the relational-needs of each other and respectful in their transactions with each other, the feedback they provide becomes a valuable asset in promoting each person’s growth.

I often begin a Relational Group Process with a focus on teaching the importance of an intersubjective perspective within the group by encouraging group members to be empathetic, to listen, to inquire and to resonate with others. Group members learn, and hopefully appreciate, the other’s perspectives and feelings. Yet an effective relational group will also include a feedback model of “This is how I see you”. It is in integrating both the Other-Centered and Cybernetic models of working that we create an “Us” rather than just a “You” or “Me” perspective.

When group members fully listen to each other and think about how the other individual’s perceptions compare and contrast with their own, then a new experience emerges -- an experience that is uniquely different from what each individual has previously known. New understandings emerge, old beliefs change, and new emotional experiences occur. It is through shared affect and perceptions that old emotional experiences can be integrated with current relationships that are uniquely individual and simultaneously uniquely relational. In doing so, we create a place that belongs solely to no one in particular and yet it belongs to each and all – a creative place of relationship.

This reciprocal process of active involvement with other group member’s perspectives and respectful reactions enables everyone in the group to both elaborate and enrich their expressions of their own experiences. Relational Group Psychotherapy provides members with an opportunity to express one’s self, to be understood, to grow in emotional attachment, and to develop one’s own identity. The therapist’s task is to introduce principles and practices that normalize and validate each individual person and the multiple relationships in the group, to provide a sense of cohesion, continuity and stability, and to encourage the group members to question and challenge their beliefs, fantasies and behaviors. The therapy is in the honest and respectful dialogue.

Effective relational group psychotherapy provides a contrast between an individual’s internal psychological processes of emotional memories, script beliefs, expectations, and self regulation with the various group member’s sensitivity to relational-needs, the importance of phenomenological inquiry, and the reparative power of people’s genuine interest and involvement.

The leader’s task is to teach and emphasize the importance of active listening, validation and normalization. This is not a normalization that is placating or minimizing the significance of a problem, but a normalization that recognizes the person’s affects, fantasies, self-protective process, script beliefs and modes of coping as normal -- normal within a stressful, neglecting or traumatizing family or school context.

Relational Group Psychotherapy takes the psychotherapist out of the center of the group, out of the task of interpreting, and out of the role of working individually with each person, and puts the focus on the relationships between group members. The leader is a teacher about human needs and relationships, guiding and facilitating involved relationships among group members. The image I use of a Relational Group Psychotherapist is that of an orchestra conductor who maintains the rhythm, adjusts the volume, gestures to the various musicians when to play their solos, and facilitates the orchestra’s playing in harmony with each other.

A guiding principle of Relational Group psychotherapy is the respect for each person’s integrity and phenomenological experience. Through respect, kindness and compassion, each member of the group establishes an interpersonal relationship that provides affirmation of the other’s integrity. Contact between group members is the therapeutic context in which each person explores his or her feelings, needs, memories, and perceptions. This does not mean that a Relational Group Process is all about being “nice and superficial” with each other. On the contrary, when we truly engage in using the best of a cybernetic-feedback model, whether it be through the use of self-definition, making an impact or initiating with another, it may involve uncomfortable discussions, challenges to the other person’s perspectives, or confrontations of their behaviors. Through the integration of the other-centered and cybernetic models, discussion, challenge, or confrontation done with honesty and respect for the other’s perspective, in a non-humiliating way, often builds trust in the relationship.

Healing relationships are based on caring involvement in the act of working together for a common benefit of each group member’s welfare. One of the tasks of the group psychotherapist is to facilitate the group members to inquire about each other’s phenomenological experience and to draw out other group members who are not actively participating or who may be reluctant to talk about what they are feeling. An illustration of this occurred in a group session where Charles spoke about the stress he felt in the painfully protracted illness and eventual death of a dear friend. His grief was intense. He then thanked both the group members and the psychotherapist for their encouragement and support in talking about a topic in which he was hesitant to speak. He described the relief he felt after talking and crying about his pain with the group. He talked with each of the group members about how his grief had shifted to a sense of appreciation for how his life had been enriched because of the friendship. With the group leader’s encouragement he then inquired about the experiences of two others in the group who had not spoken and had recently experienced the death of loved ones. They both said that they found it difficult to speak about death and their lost relationships because of the fear of being overwhelmed with intense sadness but, in witnessing Charles’ emotionally filled story, they were able to express some of their own grief. This led to the whole group talking about the importance of interpersonal connections, loss, sadness, and how they each had a history of distracting themselves from the intensity of their feelings.

In Relational Group Psychotherapy the therapist is not the only one to support, inquire and encourage group members to express themselves. Group member’s inquiry and empathy with each other and their encouragement for everyone to be heard, may constitute the most psychologically supportive transactions because they may express a shared experience of similar loss, stress, neglect or trauma.

Relational group psychotherapy often begins with recognition of each person’s needs and feelings. The leader will often encourage the group to focus on each person’s need for security, the freedom to be “as they are” without criticism, ridicule, or putdown. One of the first steps in preventing and healing stress, in the undoing of cumulative neglect, and in the resolution of trauma is for each person to have an assurance of freedom from being shamed in the group. This is often accompanied by encouraging group members to talk about past humiliating experiences and how they were hurt, angry or remain fearful in a group. Sometimes group members are invited to remember specific scenes from family or school experiences and to talk about their experiences. Often it is the implicit memories and archaic ways of relating that are reenacted within the group. The emphasis may then shift to what the person needs differently from group members in order to feel secure. Such conversation may move from one group member to another with a focus on the type of security each needs from the other.

In a group that had met for a few sessions, the discussion among the members seemed to become superficial. I began the next session by stating that no one had used the word “shame” in our previous sessions. The mention of “shame” was responded to with several minutes of silence and then each of the group members spoke of their own shame and how they often felt debilitated by their sense of “something’s wrong with me”. Over the next several sessions the entire group talked about how they were blamed or humiliated in school, in previous groups, and in their families. These discussions led group members to realize how each person needs safety in the group and they pledged to each other that there would be no shaming transactions.

Often the discussion of security leads to someone’s need for validation and affirmation by other group members. For many people their behavior or way of making meaning was discounted, ignored, or in some way not validated in previous relationships. The lack of validation is often shaming and adds to stress. Validation is provided when we find value in what the other is saying. An important task of Relational Group Psychotherapy is to provide each member with a sense of validation. For example, frequently in groups a member will say something that is full of emotion and group members will remain silent. This is often because group members think that they are being respectful. Yet, a silent response is often experienced by the speaker as a lack of validation of their affect. The person may begin to doubt themselves and what they are saying; internal stress, shame and withdrawal may result. It becomes the leader’s job to identify such moments in the group when there is a lack of validation and to encourage members to speak about what they are feeling in response to the person. Group members are encouraged to inquire about each other’s phenomenological experience and to provide an emotionally validating response.

Each of us needs to rely on others who are stable, dependable, and protective. The psychotherapy group can fulfill this need when group members consistently respect each person’s affect, fantasies and self-protective process. The group provides a protective function when there is a secure venue and the necessary attunement and involvement to understand the emotional expression or implicit memory that a member is experiencing. For example, in some groups I emphasize the significance of the larger unconscious story that a member is enacting in his or her behavior and the importance of patience and acceptance as a way to provide stability and dependability.

All of us have the need to have our personal experiences confirmed. Confirmation occurs when we are in dialogue with someone who understands because he or she has had a similar experience. The group leader watches for and encourages members to talk about how they identify with what a person may be saying that is similar to their own experience. Frequently the conversation then flows between several group members with each contributing the uniqueness of their own experience. It is in the shared experiences that people do not feel alone or worry that they are strange or crazy. Shared experiences are an important antidote to shame and an important reduction of stress.

In addition to shared experiences and similarities, each person in the group is uniquely different. People have the need to know and express their own self-definition and uniqueness and to receive acknowledgement and acceptance by the others in the group. Self-definition is the communication of one’s self-chosen identity through the expression of preferences, interests, and ideas without humiliation or rejection. The Relational Group Psychotherapist encourages each person’s expression of identity and integrity and the group’s normalization of the need for self-definition. In some family and school situations the child’s attempts at self-definition were ridiculed or punished. When self-definition is thwarted, internal stress increases. An effective group facilitates each individual in defining his or her self in relationship with others.

One of the important tasks of the group psychotherapist is to teach each of the group members how to engage in a phenomenological inquiry. Each response a person makes to a phenomenological inquiry is an expression of identity – another self-definition.

All people have the need to make an impact on others with whom they are involved. An individual’s sense of competency in relationship emerges from attracting the other’s attention and interest, influencing what may be talked about, and effecting a change of emotion or behavior in the others. Attunement to a group member’s need to make an impact occurs when the other group members allow themselves to be emotionally impacted by the speaker and to respond with compassion when the speaker is sad, to provide an affect of security when the person is scared, to take the other seriously when he or she is angry, and to be excited when he or she is joyful.

Many people in group need the others to initiate contact, to have the others reach out in a way that acknowledges their presence and demonstrates their importance in the relationship. The group psychotherapist models initiation, teaches about the importance of initiation and encourages members to initiate with each other. So often people are hesitant to initiate because they imagine that they may be invasive or they remember rules from school that prohibited children from talking to each other during class. The initiation that group members do with each other often reduces stress in the group. For example, a group member may say to another, “I noticed that you have been silent for a while. I would like to know what you are experiencing”. This initiation is an invitation to be fully involved.

The need to express thankfulness, gratitude or to give affection is important in human relationships. When group members provide a sense of security, validation, stability and dependability, a shared experience, an opportunity for self-definition and impact, and show initiation with each other, individuals are often grateful and want to express their affection. The effective group leader facilitates members in expressing their thankfulness and gratitude.

It is this trust, a shared relationship, validation, consistent reliability and security, and ongoing responses to each individual’s relational-needs that puts an end to shame, rectifies cumulative neglect, dissolves chronic stress and heals trauma.

Footnote:

This article was presented as a Keynote Address at the 4th International Integrative Psychotherapy Association Conference, April 17, 2009 in Lake Bled, Slovenia. The theme of the conference was “Acute Trauma, Cumulative Neglect, and Chronic Stress”.

Author:

Richard G. Erskine, Ph.D. is a licensed Psychoanalyst and Clinical Psychologist. His background includes Client-Centered therapy, Gestalt therapy, Transactional Analysis, and Contemporary Psychoanalysis with an Intersubjective perspective. He is the Training Director at the Institute for Integrative Psychotherapy, 500 East 85th Street, New York, NY, 10028, USA. Phone: 212 734 5291. E-mail: IntegPsych@earthlink.net. Web site: www.IntegrativeTherapy.com