Focus, structure and content of integrative interpretation in long term group psychotherapy (GP)

Abstracts

INTRODUÇÃO: O psicoterapeuta de grupo é confrontado, em cada sessão, com uma miríade de situações, das quais retira o conteúdo de interpretações que acredita ser o mais apropriado para cada indivíduo e para o grupo. Ele precisa, por exemplo, decidir sobre qual conteúdo deve focar sua interpretação. Seria melhor o foco sobre o indivíduo, sobre a interação entre indivíduos ou sobre o grupo-como-um-todo? OBJETIVO: Descrever detalhes das 33ª e 34ª sessões de psicoterapia de grupo (PG) para explicitar foco, estrutura e conteúdo da interpretação integrativa. MÉTODO: A seleção conveniente de duas sessões consecutivas de PG com oito pacientes adultos, de elevado funcionamento mental, de ambos os sexos, se deu por ocasião da admissão de dois novos membros. Foram utilizados conceitos psicodinâmicos atuais para a aplicação da técnica da interpretação integrativa nas sessões selecionadas. RESULTADOS: A expressão de hostilidade predominante na 34ª sessão revelou a ambivalência e o conflito em PG coincidindo com a admissão e a incorporação de dois novos membros. A liderança pontual do psicoterapeuta fez uso da interpretação integrativa com base nos conteúdos das sessões 33 e 34 e em sessões de conteúdos correlatos do passado do grupo. DISCUSSÃO: A interpretação integrativa contemplou quatro níveis de funcionamento grupal: 1) individual; 2) subgrupo de dois membros; 3) grupo-como-um-todo; e 4) regressão do grupo para um estágio anterior e menos elaborado de desenvolvimento. CONCLUSÃO: Em primeiro lugar, o psicoterapeuta procurou manter a expressão de hostilidade entre dois membros em nível de segurança. Depois, usando interpretação integrativa, ajudou o grupo a transcender-se a si mesmo e a compreender a experiência cognitiva e emocional em jogo na 34ª sessão, em especial a luta por dominância entre novos e antigos membros.

Psicoterapia de grupo; psiquiatria psicodinâmica; grupanálise; interpretação; dinâmica grupal; psicoterapia

ORIGINAL ARTICLE

Focus, structure and content of integrative interpretation in long term group psychotherapy (GP)

Foco, estructura y contenido de la interpretación integrada en psicoterapia de grupo (PG) de larga duración

José Onildo Betioli Contel^I; Jair Franklin Oliveira Júnior^II

^IPhD. Professor, Department of Neurology, Psychiatry and Medical Psychology, School of Medicine of Ribeirão Preto (FMRP), Universidade de São Paulo (USP). Psychiatrist, group psychotherapist and member of the American Group Psychotherapy Association. Graduate studies advisor, Graduate course in Mental Health, FMRP/USP

^IIPhD. Professor. Department of Medical Psychology and Psychiatry. Faculdade de Ciências Médicas de Campinas (UNICAMP.) Psychiatrist and group therapist

^{Correspondence}

ABSTRACT

INTRODUCTION: In group psychotherapy, group leaders are confronted with a myriad of variables in attempting to frame an interpretation that will be the most useful for the individual and the group. They must decide, for example, where to focus their interpretation: should it be on specific individuals, on the interactions between individuals, or on the group-as-a-whole?

OBJECTIVE: To describe details of the 33rd and 34th sessions of a psychotherapy group to reveal structure, focus and content of integrative interpretation.

METHOD: The convenient selection of two consecutive sessions of this group including 8 high mental functioning adult patients of both sexes, occurred on the occasion of the admission of two new members. The predominant content, mainly the hostility, in the 34th session, were analyzed by means of up to date psychodynamic concepts.

RESULTS: The predominant hostility in the 34th session showed the ambivalence and the conflict over the entrance of two new members. The group leader employed integrative interpretation based on the contents of the 33rd and 34th sessions and on previous sessions in which correlated issues were discussed.

DISCUSSION: The integrative interpretation took into account four group levels: 1) individual; 2) sub-group of two individuals; 3) group-as-a-whole; and 4) group's regression to an earlier, less developed stage.

CONCLUSION: First of all, the group leader intervened vigorously to keep conflict and hostility within constructive bounds. Secondly, by means of integrative interpretation, the group leader helped the group transcend itself to understand the cognitive-emotional experience unraveling in the 34th session, mainly the struggle for dominance between new and old members.

Keywords: Group psychotherapy, psychodynamic psychiatry, groupanalysis, interpretation, group dynamic, psychotherapy.

RESUMEN

INTRODUCCIÓN: El psicoterapeuta de grupo siempre se confronta, en cada sesión, con una serie de situaciones de las cuales retira el contenido de interpretaciones que cree ser el más apropiado para el individuo y para el grupo. Él necesita, por ejemplo, decidir sobre qué contenido debe centrar su interpretación. ¿Sería mejor el enfoque sobre el individuo, sobre la interacción entre los individuos o sobre el grupo en su totalidad?

OBJETIVO: Describir detalles de las sesiones 33ª e 34ª de PG para explicitar enfoque, estructura y contenido de la interpretación integrativa.

MÉTODO: La selección adecuada de dos sesiones consecutivas de PG de ocho pacientes adultos, de elevado funcionamiento mental, de ambos sexos, se hizo por ocasión de la admisión de dos nuevos miembros. Para la aplicación de la técnica de la interpretación integrada en las sesiones seleccionadas, se utilizaron conceptos psicodinámicos actuales.

RESULTADOS: La expresión de hostilidad, predominante en la 34ª sesión, reveló la ambivalencia y el conflicto en PG coincidiendo con la admisión e incorporación de dos nuevos miembros. El liderazgo puntual del psicoterapeuta se utilizó de la interpretación integrada con base en contenidos de las sesiones 33ª e 34ª y en sesiones de contenidos correlativos, del pasado del grupo.

DISCUSIÓN: La interpretación integrada consideró cuatro niveles de funcionamiento del grupo: 1. individual; 2. subgrupo de dos miembros; 3. grupo en su totalidad y; 4. regresión del grupo para un estadio anterior y menos elaborado de desarrollo.

CONCLUSIÓN: En primer lugar, el psicoterapeuta buscó mantener la expresión de hostilidad entre dos miembros en un nivel de seguridad y enseguida, usando la interpretación integrada, ayudó al grupo a trascenderse y comprender la experiencia cognoscitiva y emocional en la 34ª sesión, especialmente, la lucha por dominación entre los nuevos y los antiguos miembros.

Palabras clave: Psicoterapia de grupo, psiquiatría psicodinámica, análisis de grupo, interpretación, dinámica de grupo, psicoterapia.

INTRODUCTION

The natural instinct of family union was considered a very strong power for the Greeks of the classic period. Plato knew it very well and did not want all this power got lost because of the State cohesion ideals. In The Republic, it is implicit that it is from social cohesion that sense and value are given to each individual's life and action. These are the first explanations for the power of attraction and repulse that operate in human groups, which indicate the irreducible gregarious genetic instinct of the human being¹.

At the end of the 19^th century and early 20^th, the discovery of infective contagious diseases raised the possibility of an emotional contagion, as if the individual's emotions could contaminate everybody around him or her. The human being tendency of being suggestible and having an uncontrollable imitative behavior may be the root of this idea. Such behavior is known as "herd effect", and economists have already employed the term to explain why stock exchange investors take great risks by betting all in the same decisions.

In psychoanalysis, Freud assigned the origin of this power to an unconscious psychological and fraternal identification among individuals,² devoid of sexual components and resulting from an original parricide.³ Since then, the existence of a group psychodynamic unconscient has been accepted.

Foulkes,⁴ in the mid 20^th century, characterized the free discussion that circulates in therapeutic groups as equivalent to the free associations that take place in individual psychoanalysis and, therefore, subjected to understanding and psychoanalytical interpretation. The same happened with the concept of group cohesion,⁵ which reached the status of primary therapeutic factor, equivalent to the individual psychotherapy alliance.

Today, it is well accepted that in the space of group therapy there are cross relations occurring in different directions. The therapy allows identification of each member with the leader and with the other members, resulting in the formation of sub-groups, and, after the cohesion phenomenon constitutes a group as a whole, all members have identities in common. Cohesion is meant to be the attraction that all group members have for each other and for the whole group.

The way how group members realize the cognitive-emotional content in each session varies according to the vicissitudes of the group during the session, but developing an interaction with previous experiences that are stored in the group's memory and culture since the beginning of the psychological treatment.^6,7 Therefore, each session can potentially produce a myriad of situations, which should be interpreted and receive all the concern from the psychotherapist.

On the one hand, members may realize the group as an ideal combined parental and kind figure, which protects everyone and strives for safe and constant emotional growing. But on the other hand, the group can be seen as an evil spirit that chases participants and wants personal annihilation and destruction. It is under responsibility of trained psychotherapists to identify these extreme behaviors and find the suitable techniques to moderate the expression of conflicts that may arise during treatment sessions, within endurable and constructive limits.^8-10

The models applied to group psychotherapy (GP) interpretation have three major goals: the patient as an individual within a group, parts of the group that can be identified as sub-groups, and the group as a whole. The present study approaches and presents a type of interpretation that takes into account the evolution of the GP in successive phases, and the formation of a group culture by the accumulation of experiences of previous sessions; both contributing to the elaboration of the group's therapeutic treatment. The interpretation we are approaching here comprises the elaboration and the explicit utterance of the psychotherapist insight, and that is the reason why it is named integrative interpretation.

The main goal of the present study was to analyze the 33^rd and the 34^th sessions of a GP as for the transformations that occurred in the environment of solidarity and harmony to the later development of a severe contend, hostility and therapeutic regression. We stress points as focus, structure and content of the integrative interpretation.¹¹

METHODS

Subjects and group. Both sessions selected were of open, weekly and long term group therapy. Each session lasted 1 hour and 30 minutes and was composed of 8 adult participants: 4 male and 4 female.

Inclusion criteria. Patients were university students ranging from 20 and 32 years-old, studying in local universities and with no problems to reach the GP place. Four had a diagnose of anxiety disorder, three of depressive episode and one of personality disorder. The psychopathology intensity at the treatment onset was between mild and moderate. No patient was taking medications.

Psychotic patients, severe personality disorder, and psychoactive-substance dependants were excluded. The inclusion of patients was based on the idea of composing an homogenous group as for the power of self, ability of introspection, psychological awareness, motivation to change, and strength to tolerate interpersonal stimuli within the group.

All participants looked for treatment because they had been facing difficulties in interpersonal relationships and had mild and moderate symptoms generically described as dysphoric feelings of rage, restlessness and depression. The majority were single. Two members were admitted in the 33rd session, one of which was about to get married. The other six patients had been under treatment for eight months.

Record. Sessions were transcript after the end of each group session, and contents were qualitatively analyzed.

Technique. Complexity and subjective refinement in the 34th session were analyzed under the light of the integrative interpretation.^12,13

RESULTS

All group members were present in the 33^rd session. The two new members seemed to be very well accepted and their arrival was seen as a positive factor of group enlargement that would bring fresh air and renewed hope to everybody. In those moments of positive acceptance and reciprocity, well-educated greetings, which are usual in any social group, were repeatedly performed. The positive welcoming stimulated a new member - a boy - to occupy most of the session with a topic loaded with anxiety and cry. Feeling uncomfortable, he talked about being abused by his father and older brother in the past. He still felt as if his privacy was invaded, and named the situation as symbiotic. He was living with the uncomfortable sensation that he did not have his own life. Only in the 4^th year of the Law School he said he could realize how much he had been hampered. He was afraid of repeating that kind of relation, which he named crazy, with his future wife, and promised to try his best to get rid of it. Crying, he kept on saying that he should solve this situation. When he finished, the other members offered their support to him.

Another member of the group, who was a Law student as well, said he was feeling relieved for the identification with the new participant, because he was also physically abused during his childhood by an authoritative mother. Those honest and sincere revelations broke the silent in the group and diminished the initial isolation of the new members, opening space for older members to express their solidarity.

In the following session (34^th), two old members did not come; one of whom had considered the group increase from 6 to 8 members as highly positive. At the beginning of the 34^th session, an old member of the group (married, Medical student boy) surprised everybody by emphatically criticizing the new patient's father and brother, the topic that occupied a quite large part of the previous week's session. He said he had had some business with his brother some time ago, and said that not only it did not work as still today he had money to receive. The emotional tone was loaded with denouncement and public attack, which soon made the new patient to defend himself and his older brother.

The threatening tone and the surprise caused by such an unpleasant ending made the rest of the group remain mute, constrained and paralyzed by an intense emotion. The climate was of consternation by the increasing hostility that contaminated the group.

DISCUSSION

Focus and structure of the integrative interpretation

In the 33^rd session, there was a predominant climate of cohesion all over the session. The frank and honest revelations of the new member were realized as a catharsis that helped to integrate him to the group and yielded the others to provide support. The free discussion allowed participants to share information about similar situations they had already experienced.

The development of the 33^rd session enabled an environment of great attraction between new and old members. The new member's arrival could not have been better. The moment was propitious for intimate revelations and the persistence of constructive conflicts and confrontations during the session made everybody believe the psychotherapy efficacy. Mutual acceptance, reciprocal support and the promise of maintenance of significant group relations in the future were predominant in the group

The psychotherapist considered evident that in the 33^rd session the patients were demonstrating a great autonomy and self-administration in their therapeutic treatment. The continuous search for a frank and constructive dialogue within the group expressed that feeling. In this session, the coordinator undertook the formal task of structuring the setting, opening the session and waiting the patient's manifestations. During the meeting, the psychotherapist followed the discussions attentively, demonstrating he understood the development and meaning of contents approached. After one hour and a half, the session was ended at the previously arranged time.

In the 33rd session, leadership could be performed with apparent smoothness and calm. However, in the 34th session, it was challenged and required, as the group underwent a severe risk of therapeutic elaboration level loss. Under these circumstances, the psychotherapist had to carry out the following actions:^14,15

1) to transfer the focus from the "contending pair" to himself, with the goal of interrupting the dangerous hostility and increasing constraint;

2) to declare the pair as the group's expression of momentary and overwhelming passion soon transformed into hate;

3) to consider as a cause and effect relationship the contrast between the noise made by the "contending pair" and the silence of the other four members;

4) to show the lack of coherence and the contrast between the warm and peaceful reception in the 33^rd meeting and the discussion;

5) to make clear that the quality and the exaggerated intensity of the pair's emotion content were originated in the past, in relations out of the group, but they were strong enough to paralyze the group as a whole during the 34^th session;

6) to describe the process during the 34^th session, in which the pair represented the fight between new and old members for the group's dominion, with release of unbearable persecutory primitive anxieties, like fight and escape.

7) To show that the anxiety demonstrated in the 34th session was a regression to an earlier point, with less elaboration and capacity of cognition-emotion integration, and a drawback in the integration of the group, which had already been reached.

Cognitive interpretation

The psychotherapist turned towards the contending pair and said to the new member: "During last week's session, you talked about the symbiosis you had with your father and, specially, with your older brother, and told us that you feel invaded and abused. As for you [towards the old member], around 6 months ago, when we were in six in the group, you said your professors and your wife were abusive people because they talked to each other about your performance at school, because they wanted to avoid you come to fail. What I mean is that you have a long and painful past of abuse in common."

"However, in the group, you forget the peculiarities of your past, and behave as if you identified each other as the abusive person, justifying mutual hatred and reciprocal need of attack and defense. The other participants neglected and remained silent, as if they could run away form this moment."

"They could be protecting themselves against a revival of a real abuse they suffered in the past or in their imagination, something they could have suffered or caused. Instead of including themselves in a self-examination about abuse, benefiting from the honest, sincere and emotive revelation you both did, the silent ones preferred to treat you as the speaker person that carries feelings of hatred, guilt and remorse away from them."

"The absence of two participants today may be reflecting their difficulty to accept the new ones. Notice how we are split in two groups today. It is as if the contending members represented the new and old members fighting for the group's dominion from now on." "There is a real competition to see who is going to lead the group in the future. This is, however, a fratricidal and inglorious fight. The defeated will dye symbolically and the winner will feel the taste of guilt and depression. This is a sterile combat, like you win but there is no prize. I think you expect I do not take the side of one or another, but that I try to help you to avoid a tragedy, like the abandonment of treatment by one of the contenders or, even worse, the destruction of our group.¹⁶"

CONCLUSIONS

The psychotherapist deviated the group's attention to himself and thus interrupted a dangerous fragmentation generated by increasing hostility between the two members. Proceeding like this, the therapist ensured a setting of moderation, confidence and group's cohesion. The destructive potential of the unconscious conflict for dominion was transformed into a rational opportunity to examine the differences between people, minimally neutral therapeutic control. The integrative interpretation included the individuals, the contending pair, the group as a whole, and explained the regression to a previous and less elaborated phase. It allowed the psychotherapist to deviate the focus from the members' past and daily life to the elucidation of the origins of hostility, using the immediate interactions of the 34^th session. The technique was shown to be useful in the retrieval of the therapeutic elaboration level and proceed with the work of new member's assimilation.

REFERENCES

Received on January 04, 2005.

Revised on January 04, 2005.

Approved on February 23, 2005.

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Publication Dates

• Publication in this collection
  15 Sept 2005
• Date of issue
  Apr 2005

History

• Received
  04 Jan 2005
• Reviewed
  04 Jan 2005
• Accepted
  23 Feb 2005