Medium 9781855758308

Integrative Psychotherapy in Action

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What is integrative psychotherapy? How effective is the integrative approach to therapy? And what are its limitations? Answering these and other significant questions, this insightful volume provides the working clinician with a practical guide to using an integrative approach to psychotherapy.Erskine and Moursund, both experienced psychotherapists, begin their discussion with a masterful theoretical overview which integrates diverse concepts from various therapy techniques such as psychoanalysis, client-centred therapy, and Gestalt therapy. The authors then use transcripts of actual therapeutic sessions (with explanatory comments interjected) to provide the reader with a broader understanding of both theory and its application in therapy - and to capture some of the elusive essence of the ongoing therapy interview.Unique in its attention to detail, as well as to the therapist's own decision-making process, advanced students and therapists alike will find this volume an invaluable resource.

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1. Introduction

ePub

Most psychotherapists date their beginnings from the work of Sigmund Freud. It was Freud who first attempted a detailed explanation of the way in which unconscious processes affect behavior and of the way in which early patterns of feeling and believing continue to shape how we think and feel as adults. Freud's “psychodynamic” approach became a touchstone of modern psychology. Except for the strictest of behaviorists, no psychotherapy is unaffected by Freud's work, though some schools of thought borrow from and build upon it more directly than others.

During the early decades of the twentieth century, Freud's version of psychotherapy dominated clinical practice in both Europe and America. To be sure, there were occasional exceptions—physically oriented treatments like complete bed rest, regimens of strenuous exercise, education and exhortative programs, or the use of hypnosis in treating mental disturbance—but these were small islands in a sea of treatment by “psychoanalysis.” By the 1930s, a new generation of therapists was emerging: among them Carl Jung, Alfred Adler, Wilhelm Reich, Otto Rank, Karen Horney, and Harry Stack Sullivan. As their voices and influence grew stronger, they not only expanded the vision of psychotherapy beyond Freud's vision (Geiwitz & Moursund, 1979) but also contributed many of the essential concepts of integrative psychotherapy.

 

2. Conrad: Regression and Redecision

ePub

The script is our personal blueprint for how we will live our lives: how we experience ourselves, others, the world around us; what we expect will happen if we behave in one way or another; how we feel and what we tell ourselves about those feelings. Begun in earliest infancy, the script comes together into a more or less coherent whole during childhood and is elaborated on and added to throughout our lives. Psychotherapy, if it is to effect lasting change, must affect script. It is script change that allows the client to experience him- or herself as truly different. As the script changes, new options for thinking, feeling, and behaving become salient. In Chapter 1, we described four domains of script-changing therapy: cognitive, behavioral, affective, and physical. Script may be changed through discovering new ways to think (and fantasize) about self and others; through trying out new behaviors in an “experimental” way; through making changes in biochemistry, musculature, or movement patterns; or through reworking the feelings present when the script was formed and as it becomes reactivated in later life. All four of these domains may become involved as the client is led to return, emotionally, to the point in time at which the early decisions and beliefs and perceptions were acquired, and to literally reprogram replacements for that which is no longer working.

 

3. Chris: Discovering a Self-Created Parent

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Conrad's work, presented in Chapter 2, illustrated the weaving together of cognitive, affective, physiological, and behavioral components in the context of a will to change. As we have seen, alterations of script typically involve several—if not all—of these elements. The work can focus primarily on changing cognitions (beliefs about self, others, the nature of life), or on changing feelings (the sense of “having to” react emotionally in a certain way), or on changing actual overt behavior. Script changes can be made with regard to parental figures, peers, or stressful events in the client's life. Or the client may merely uncover and understand the early decision, and choose to process its implications for a while without making a new decision during the therapy session, saving the actual redecision for a later time.

The following piece of work is an example of the latter process: The client does not make a clear redecision in the work itself. Chris works early in the course of the workshop, and works exclusively with Richard. Chris knows that he will have ample opportunity for follow-up. Richard allows him to explore the thoughts, feelings, and behaviors that surrounded his early experiences, and ends the work in such a way as to encourage him to continue this process as the workshop progresses. The intent to change is clearly present, and it is this intent that will carry the impact of the therapeutic work into the structure of the client's everyday life. The work also introduces a number of themes, concepts, and techniques typical of integrative psychotherapy, and will further illustrate the way in which we conceptualize the structure of personality and the avenues through which change can be accomplished.

 

4. Ben: Therapy with the Parent Ego State

ePub

Central to script theory is the concept of the childhood decision. These decisions, often begun even before the individual has words to conceptualize what is being decided/experienced/understood, continue to shape our script throughout our lives. The early decision sets up expectations, which lead us to find and interpret new situations so as to strengthen or reinforce the decision, “proving” that the old way of thinking and feeling and being was indeed the only possible choice. Regression work is a major technique for dealing with this sort of script decision.

Not all script, however, is most usefully characterized as formed through a decision-making process. As was described in Chapter 1, the beliefs, attitudes, feelings, and behaviors of one's parents (or other primary caretakers) are taken in by the child, swallowed whole. The child has no choice about this kind of scripting; the thoughts and feelings and behaviors permeate the very atmosphere, and the child must breathe them in if he or she is to breathe at all. Such introjected material forms the Parent ego state, and when this ego state is cathected, it is as if the introjected parent(s) had psychologically replaced their now-grown-up offspring.

 

5. Frankie: The Absent Father

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By far the most common occurrence in therapeutic regression work is that a client works through conflicts with one or both parents. We have seen Conrad dealing with his mother in Chapter 2, and Chris preparing for a confrontation and decommissioning a self-created Parent in Chapter 3. In the piece of work presented in this chapter, the client is also dealing with a parent, but it is an absent parent who is the focus of the work.

Frankie's father died when Frankie was an infant. His mother, herself highly dependent, was overbearing and abusive of Frankie, using him to deal with her own needs rather than providing him with clear limits and appropriate nurturance. Frankie grew into his teens as an obese, socially isolated adolescent. With no effective male models, he failed to develop an adequate gender identity and experienced himself as nonsexual. In his early twenties, he began intensive psychotherapy, and was able to resolve much of the conflict around his dealings with his mother. At 33, he looks 23: a now slim, quiet, adaptive young man who is beginning to experiment with both homosexual and heterosexual relationships. Father, however, has remained an important though shadowy influence throughout his life.

 

6. Robert: Challenging a Cultural Script

ePub

In dealing with introjected script material, we typically work with a personification of one or both of the client's actual parents. Occasionally, though, an introjected ego state had its origins not with the actual parents, but with some other person or people. Other family members (older siblings, grandparents, aunts and uncles), neighbors, teachers, clergy—all can be sources of intro-jection. Whether the scripting comes from an actual parent, or from some other influential individual, working with this kind of introject tends to follow the same general procedure.

There is another kind of Parent ego state content, though, that is not introjected from a single person. Cultural scripting consists of introjected thoughts, feelings, attitudes, and behaviors that are taken in from a multitude of sources. Cultural scripting often determines the kind of music we enjoy, the foods we refuse to eat, our attitudes toward people of different races or religions. This sort of scripting is not always a negative influence: a fondness for Beethoven, or spoon bread, or a sense of comfort derived from the sound of ocean waves crashing on the beach can be sources of great pleasure. It is when these attitudes and expectations limit our options and interrupt our ability to be flexible and creative that they may become a focus of therapy.

 

7. Emily: From Dream to Script

ePub

In ordinary clinical practice, clients seldom walk into the office, sit down, and begin to deal with their basic conflicts. Many new clients present the symptoms of their problem, and do not understand that the roots of their present discomfort are deeply buried and out of awareness. The therapist needs to respect the presented problem, while at the same time focusing on the deeper issues.

Workshop and intensive group participants, too, are often unaware of where their work will take them. Although these clients are frequently sophisticated in the area of psychotherapy, they may be quite unaware of their own personal dynamics. It is always easier to see the forest when you're not lost among the trees!

There are many ways in which therapist and client can work together to open a path into the introjections or childhood decisions that will eventually need to be explored. Dream work is one such avenue. Working with dreams has a long and respectable history: Even before the landmark work of Freud in the late 1800s, physicians and philosophers had studied and speculated about the implications of dreams. Dream analysis today takes many forms, from the traditional psychoanalytic approach to the more active approaches of Gestalt therapy.

 

8. Sarah: The Emerging Plan

ePub

Integrative psychotherapy maintains that the client frequently knows, better than anyone else, what he or she needs to do. The client is—when not hampered by his or her own denial—the world's greatest expert on him- or herself, because he or she is the only one who lives inside that particular skin. As the client's awareness unfolds, he or she will let the therapist know what step is next in the intricate therapeutic dance. At the same time, however, integrative psychotherapists are trained to think in terms of defense mechanisms, diagnosis, and treatment planning. We expect ourselves to recognize our clients’ script issues, to look beyond their confusion and scare and resistance, to plan interventions that will help them to go where they cannot go on their own. They know best what they need—but we must know better than they. It feels like a paradox, a contradiction, which demands resolution if we are not to become paralyzed in our efforts to be both therapeutic and respectful of our clients’ inner wisdom. How can this paradox be resolved?

 

9. Bill: Replacing a Destructive Introject

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As we have pointed out in many of the preceding chapters, script is formed through defensive decisions made by the Child, or through introjects stored in the Parent ego state; most often, a given script belief or feeling involves elements of both Parent introject and Child decision. If a strongly held script belief is to be changed, the Parental aspects must be defused or decommissioned, and the Child decision must be given up or changed. Sometimes these two processes will take place in tandem; in other pieces of work, either the Child or the Parent aspect will be treated first, with a follow-up needed to deal with the other.

Identification and internalization are natural developmental processes that help a child assimilate and learn about the environment—they facilitate contact. Introjection, on the other hand, is a defense mechanism, an avoidance of contact. The young person introjects parental figures because there is no real contact with them. He or she may also use introjection to avoid conflict too intense to handle, because internal and external supports are not yet fully developed. Through introjection, the conflict is internalized, giving the child the illusion of being in control.

 

10. Glenda: The Empty House

ePub

Integrative psychotherapy emphasizes the importance of our fantasy activities. In our day- and night-dreams, our images, and our creative productions, we express the varied aspects of ourselves. Each fragment of these fantasies—each object, each person, each house or hill or ocean beach—is also a fragment of self, expressed in symbolic fashion. As we saw in Emily's work in Chapter 7, clients can be led to “decode” this symbolic language. Dreams and fantasies can be a means of discovering oneself, one's thoughts and feelings and desires that may be tucked away out of conscious awareness: once these aspects of self have been brought into awareness, they are available for psychotherapeutic work.

In the session presented in this chapter, therapists and client work not with a dream, but with a consciously created fantasy. The fantasy is built on a memory: the recollection of the house that the client lived in during childhood. This recollection is highly emotionally charged, as the client's previous work has revealed. On the surface, the emotional meaning of the house has to do with a traumatic event that occurred there: The client's father, enraged at her mother (from whom he was estranged), arranged for movers to come in and take away all the furnishings in the home. The client and her mother returned from an all-day shopping expedition to find their home stripped bare. As we shall see in the work, however, the emotional meaning of this house goes far beyond its role as the site of a painful memory. The house is a metaphor for the self, and each room and object and characteristic of the house is a symbolic representation of the client's personal experience.

 

11. Charles: A Study in Contact

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The heart of psychotherapy is contact. Contact between the self and the external world, and contact and integration within the self, defines psychological health. Contact between therapist and client encourages, fosters, supports, and invites other contact experiences.

While integrative psychotherapy makes use of a broad range of concepts, the notion of contact remains basic. As we have seen in previous chapters, contact pervades and undergirds all of our work. Often, the importance of the contact itself is overshadowed by the drama of other aspects of the therapy—an important redecision, an intervention with a Parent ego state, the reworking of a dream or fantasy. The piece of work presented in this chapter has none of these; it is a nearly pure example of contact.

As you read through the transcript, notice the ways in which the therapist consistently maintains and invites contact. Every comment, question, paraphrase, or interpretation has two primary goals: furthering a sense of contact between therapist and client, and enhancing the client's awareness of internal sensations, experience, and memory. Any other benefits are of secondary importance.

 

12. Jon: Putting It All Together

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We have come a long way and have met a lot of people in this book. We have introduced a variety of theoretical concepts, borrowed and adapted from the work of many of our predecessors in the gentle art of psychotherapy. We have described, discussed, and dissected many techniques and have shown how they can be used and what they can be expected to accomplish. And all of this has been a rather freewheeling consideration of ideas as they arise in the rich and varied context of ongoing psychotherapeutic encounters.

We have chosen Jon's work as the basis for this last chapter because it gives us an opportunity to wrap many of these ideas together: to show how one concept complements another, how one type of intervention grows out of a particular theoretical idea, and how a hypothesis about a client is often the product of (or refuted by) a particular series of interventions.

Jon's transcript, then, will illustrate many of the major theoretical underpinnings of integrative psychotherapy. We shall see examples of interruptions to internal and external contact, of Child ego state fixations, of the introjection of a segment of a significant other's personality, of the intrapsychic influence of a Parent ego state and the resulting defenses, and of childhood script decisions in which the entire script system maintains itself through a circular, self-reinforcing process. We shall also see many of the therapeutic techniques that have been discussed in previous chapters: the Parent Interview, the process of heightening awareness of defenses and enhancing contact, the attention to each of the major domains of therapeutic change.

 

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