Kaoru Nishimura International Christian University (Tokyo)/ Adelphi University Derner Institute NY Area RA Seminar on June 5, 2008.

Kaoru NishimuraInternational Christian University (Tokyo)/

Adelphi University Derner Institute

NY Area RA Seminar on June 5, 2008

Intrapsychic process (multiple code theory) vs interpersonal process (group psychotherapy)

A model of emotional communication by Bucci (2001)

Possibilities of multiple code theory for group psychotherapy

Merits on the part of multiple code theoryThis study aims to examine theoretical and

technical issues in group psychotherapy from the viewpoint of multiple code theory

Bucci’s (2001) “pathways of emotional communication”

“he expresses the affective core of the schema directly in subsymbolic formats, in myriad ways…”

“The affective core of subsymbolic processes is aroused but is not connected to the representations of objects and images.”

Bucci’s (2001) “pathways of emotional communication”

“..she will generate imagery, reflect on this, and eventually come to some emotional understanding of the state that has been activated in her. The analyst infers an understanding of the patient's state—as yet opaque to the patient—on the basis of these inner transformations of her own experience..”

Bucci’s (2001) “pathways of emotional communication”

“If the words are effective, they will evoke imagery for the patient that connects to his own somatic and sensory experience. The imagery …must be generated by the patient..”

Bucci’s (2001) “pathways of emotional communication”

“If the therapeutic work is successful—the patient will respond in such a way as to indicate that a circle of emotional communication has been successfully completed. The indicators may be both in symbolic form…and in subsymbolic form.”

Its aim is, just like individual psychoanalysis, “structural change” or in multiple code theory, to make referential process work more flexibly by symbolizing subsymbolic contents

A therapist reports recurrent fantasies of wanting to choke a certain man in the group. His would-be victim is a man who constantly smiles, who announces how well his life is going, and who even compliments the therapist and the group. When one day this member announces that he

won’t be at the next session and, with a gleeful look, describes the Caribbean vacation he is planning, one that will cost a fortune, our therapist has the vivid fantasy of rising from his chair, walking over and wreaking his havoc. In the fantasy, the therapist sees himself as Clint Eastwood annihilating a crooked politician.

Curiously, in this case, the therapist feels no anger toward the member; he has only the fantasy, but the aggression behind it is easily inferred, even though it is not felt.The therapist’s examination of his fantasy, in this

case, leads him to discover that he is being treated with contempt. His patient has been saying to him, “You are merely a form of diversion and not my favorite one at that.” Using the knowledge, the therapist finds it

effortless to endure future slander of the same kind. He proceeds to help the group become cognizant of what the man is doing, to them as well as to the therapist himself. Everyone profits.

A woman therapist suddenly has the fantasy that she is going to a funeral. However, she can see no reason for death to have come into her mind. She very much likes the members of her group, and right now they are chatting amiably.

At first, she tries to put her fantasy out of her mind. But it keeps recurring, and soon she feels forced to pay serious attention to it.

Studying the members, she realizes that one of her patients, Martha, is especially subdued. The therapist has no idea why, but comments on the fact. “Martha, you seem to be silent.”

With no more provocation than that, Martha bursts into tears and reports that her sister died that very week. Martha had not wanted to tell the group, suffering as she did from an almost phobic distrust of pity. However, she had told them – or more precisely, she had “told” the therapist.

In this case, the therapist’s fantasy opened up a profound discussion, not just of the deceased sister, whom Martha loved, but of Martha’s own difficulty in taking from the group what she needed – namely, their deepest expressions of caring.

The group therapist must establish an altruistic group climate by means of helping the members communicate with each other, as well as interpret and analyze the members’ resistance and transference.

Interpersonal modelYalom (1995): “in group therapy the

problem in not the importance of transference work; it is the priority of this work relative to other therapeutic factors in the treatment process.”

Cohesion of groupGroup entity

Pinney (1994); “…the mental matrix of the therapist and the therapeutic group is the engine of group psychotherapy.” “The non-specific aspects of the therapist’s mental matrix are as important as the therapist’s psychoanalytic theory.”

Group members help develop the referential process of other members by altering their roles between sender and receiver.

Mental matrix and RIGs (Stern, 1985)“feedback” from other members as

therapeutic toolBehavior and its pattern as subsymbolic

process

Bucci (2001); “Specific forms of pathology result from dissociation among different components of the emotion schemas, as well as from attempts to repair the dissociation that may be maladaptive in themselves... He may express the schema through acting out, as in impulsive behavior, or acting in, as in somatization, or may associate the arousal with another object that is not so threatening and forbidden, as in displacement.”

Failure of referential process is painful itself.Bucci (2001); “The patient then returns to

his customary state of extreme emotional detachment.”

In therapy group, the patient tends to avoid the objects that are threatening, and takes his customary interpersonal maneuvers and security operations that are rigid and unregulated in order to evade the emotions with dissociated emotion schemas.

Kindling and group dynamics help referential process occur both in and between the group members.

Pinney (1994); “In matrix interactive group psychotherapy inappropriate reactions to the therapist and group members usually become evident to other group members. They then question the behavior. Patients usually are able to clarify these transference based inappropriate reactions. When they do not, the therapist can initiate some questioning and associative mental activity.”

Pinney (1994); “Kindling, a process where subthreshold stimuli eventually cause a neuron to fire is the neurologic equivalent of what takes place verbally and by other communications between therapist and other group member, and a patient. One part of working through is like kindling. The designated patient gets hints from the associations of each group member and the therapist about his or her behavior in the group and what he or she describe as happening outside the group. Eventually the group members become conscious of what is being hinted at and it can become conscious and discussed explicitly in the therapeutic group.”

Pinney (1994); “In group psychotherapy the kindling represented in each group member by the stimulation and suggestion from each and all the other members finally reaches a critical point. A conflict becomes explicitly stated for all the group. This is expressed in the instruction to the therapist to make an interpretation when the subject is ‘hot.’ Not every summation of common agreement comes from the therapist…The sum of all the associative stimuli may be totaled by any, all or no members of the group consciously, although it is likely that a common understanding or perception will be put into words.”

Rachman (1999); “Confrontation by a peer is an important psychodynamic in a group. A peer can confront a peer without evoking the negative parental transference that can be ignited by the group analyst. Interaction with the same content and intention can be experienced as hurtful, rejecting, or even abusive, if presented by the group analyst. Therefore, it is preferable for the group analyst to encourage members to confront one another.”

“Compassionate confrontation”(Rachman, 1999)

The woman, Sandra, had not had a relationship with a man for about 15 years.

Her interpersonal contacts were with a group of women about her age, now in their late 40’s, who had never been married.

Sandra did have a love object – her cat.

Warren, a previous quiet group member, had recently developed a capacity to interact with other group members, and to initiate interaction as well. During a group session, as Sandra began

relating how “wonderful, loving, special, and important” her cat was to her, Warren initiated a confrontation.

Warren: Sandra, I want to say something to you that is very hard to say. But, I feel have to talk to you about something that really bugs me.

Sandra: (With great hesitation) I don’t know if I want to hear this.

Warren: Well, I’m going to tell you what I have to say.

AWR: Sandra, I want you to know that I feel Warren is trying to tell you about something that may be important and could help you. I trust him to be tender and loving with you. If necessary, I will help him reach you in a way that you can hear. Or, if it’s causing you too much difficulty we can stop. OK?

Sandra: OK! I’ll try to hear what you’re saying Warren, and no to be defensive.

Warren: I think you are too attached to your cat. I’ve seen this kind of relationship before. My wife’s sister, who has no one in her life, is pathologically attached to her dog. I even think she bangs her dog.

Sandra: You mean, she fucks her dog?Warren: Well, I no sure if she does, but she is so wrapped up in the big male dog, she might as well be fucking him.

Sandra: Are you suggesting I’m having a sexual…

Warren: No, I’m not. And let’s not get sidetracked. I’m saying, and again this is hard to say because I don’t want to hurt you – but, your relationship with your cat is too much.

Jeffrey: I thought the same thing, every time you talk about your cat, but I could never bring myself to say what Warren just said.

Sandra: Why not.Jeffrey: Because I felt it would hurt you. You would feel rejected – I don’t want to hurt you.

Sandra: You are very kind. I know you would not hurt me. I don’t think Warren wants to hurt me either.

Sandra turned to the rest of the group members and asked how they felt about her pet. The remaining group members agreed that there was an issue regarding her cat that was worth exploring.Her relationship with her cat, he (Warren) argued, interfered with her expressed desire to have a relationship with a man; her cat had become “her man.” Warren concluded by urging Sandra to not replace the cat when it dies and, in doing, provide emotional space for another human being.Sandra, although upset, did not express hostility or resentment to Warren. She also did not need to turn to the group analyst for any direct help during the confrontation.

Group psychotherapist is important as a real person as well as an object for transference.

Therapist is not allowed to hide behind a blank screen.

Transparency of therapist, “judicious self-disclosure,” and openness to his own mistakes are highly therapeutic.

Wright (2004) ; One day he was sitting in group next to another group member, a woman, with his eyes closed and looking very relaxed… A group member commented to him, “You look very comfortable Hugh, why’s that?” He opened his eyes and immediately responded with “Because I’m sitting next to a woman.” I do…know his response had a big impact on me. This really impressed me because up to that point I could never have admitted in public that I had such feelings about women, or even have admitted such feelings to myself for that matter….Hugh’s response in that stimulated a whole new way of thinking and feeling in me; namely, that it’s safe to relax in mixed company, if you will.”

Example of therapist’s transparency (Yalom, 1995)The group of women incest survivors – the

withering anger toward me (and, to a slightly lesser degree, toward my co-therapist) had gotten to us, and toward the end of one meeting, we both openly discussed our experience in the group. I revealed that I felt demoralized and deskilled, that everything I tried in the group had failed to be helpful, and furthermore that I felt anxious and confused in the group.

My co-leader discussed similar feelings: her discomfort about the competitive way the women related to her and about the continual pressure placed on her to reveal any abuse that she may have experienced. We told them that their relentless anger and

distrust of us was fully understandable in the light of their pas abuse but, nonetheless, we both wanted to shriek, “These were terrible things that happened to you, but we didn’t do them.”

This episode proved to be a turning point for the group. There was still one member ‘who reported having undergone savage ritual abuse as a child) who continued in the same vein (“Oh, you’re uncomfortable and confused! What a shame! What a shame! But at least now you know how it feels”). But the others were deeply affected by our admission. They were astounded to learn of our discomfort and of their power over us, and gratified that we were willing to relinquish authority and to relate to them in an open, egalitarian fashion. From that point on, the group moved into a far more profitable work phase.

Example of therapist’s judicious self-disclosure (Rachman, 1999)

One member was having scheduling problems. …It was my understanding that our new time was at 7:45 am on Wednesday mornings, so that he could have his sessions before going to work. When he did not show up for the newly scheduled sessions, I phoned repeatedly, but could not reach him. Since he did not mention it in group sessions, I assumed he wanted to keep this issue of the missed sessions private.

One day, the member began a group session saying he was quitting therapy because he was furious at me for missing the three sessions in a row, with no explanation. The group and I were shocked. He was asked to elaborate. He said he had come to the office three times at 7:45 pm…, and found the office locked. This experience had made him feel angry, rejected and unloved. I was shocked at the news that he was

quitting therapy because he felt I was unresponsive and rejecting. As I tried to review the rescheduling issue to straighten out the confusion and hurt, another female member stopped me and said:

“Don’t you see how hurt he is? He feels you’ve rejected him by not being there for you appointments. It doesn’t matter how the confusion developed. The important thing is to respond with empathy. Please tell him you’re sorry for what happened. Can’t you see he needs to hear that?”I was unhappy to be reprimanded by the

member in front of the group. But,.. she was absolutely right. I had shown my frustration and resentment by insisting on clarifying the time change – in defending my position. As I allowed the female group member’s plea for empathy to reach me, I stopped defending the schedule change and said the following:

“I can see now that you were hurt and rejected by what you feel I did to you. I regret the confusion about our new schedule. I take responsibility for the confusion. I did not mean to hurt you or reject you. I would like to talk to you about clearing up the confusion by finding a new time for your individual session that works for you.”.... The individual felt less upset, decided to

continue his therapy, and began to understand the origin of the difficulty. 

How can we explain therapist’s transparency and self-disclosure work?

From the viewpoint of multiple code theory, they change the quality of relationship by working at a high level of referential process.

They allow the affective core to connect a new and safe object. This experience contributes to integrate “old” and “new” emotion schemas.

Group as a psychological space and its representation is crucial for group psychotherapy.

Gradually, as they interact with each other in the group, their sense of safety gets extended, and they come to feel the group a part of their “selves”.

Sandler (1960); “[T]he successful act of perception is an act of integration which is accompanied by a definite feeling of safety―a feeling so much a part of us that we take it for granted as a background to our everyday experience.”

“groupself” (Kohut, 1976, Kieffer, 2001). “primary identification to the group”,

“mother group” (Scheidlinger, 1974). “psychological safe space” (Kotani, 2005),

extension of “space of the self” (Nishimura, 2008).

Ken (a male student in his late teens), who talked only about himself and repeatedly claimed, “I am not anxious at all.”In the second session, Mari (a female student in

her early twenties) commented to Ken. (KN for therapist; CoTh for my co-therapist) KN: How do you feel, Mari?Mari: Well, I was thinking about Ken a little.KN: Oh, are you? So, what did you find?Mari: I didn’t find anything. In my impression, he

is not very interested in us.CoTh: Uh-huh.

Mari: Uh, the contents of his speech, uh, I said I couldn’t get them, but he kind of said to himself. It seems there is no subject. I wonder what. I have many things I can’t understand. It looks like he is satisfied with himself.

Ken: Whoa.CoTh: Uh-huh.Ken: The last one I mentioned, right?Mari: I had no idea about that. You often said

“that” or “it,” but I couldn’t understand which one was which.

Ken: Oh.Mari: But I myself have the same tendency,

maybe. It’s difficult as you speak, I guess.Ken: I was given one aim.KN: Good for you!Ken: Yes, good, good.

Ken tried to connect a phrase with some emotions in the following third session.CoTh: (To Jun) I guess your space got bigger. You

were concerned about whether you should speak, but now you can see people. So, as you listen to other’s story, you can feel safe by seeing him. Jun: Yes.KN: Uh-huh. Does anyone feel anything?Ken: I was impressed by “feeling safe by seeing

somebody.”KN: Uh-huh.Ken: Feeling safety by seeing somebody is kind

of ... uh, it does stick to my mind. Seeing somebody, seeing such a person, well, that never made me feel safety. I am not used to it. CoTh: Oh, you are scared by seeing somebody,

right?

Ken: Uh, scared by seeing a person, let me see, mm...

CoTh: I really feel you are feeling a sense of safety in you.

Ken: You are right. I can understand it myself. Yes. It does make sense.

KN: Mari told you that you are not interested in them, huh?

Ken: Yes, yes, yes, yes. It is really to the point. Actually, well, as I said, when I seek in me, maybe, well, well, “feeling safety by seeing somebody” did stick to my mind. Not safety in the whole something, but, uh, safety straightforward within me.

CoTh: Yes.Ken: How can I say? Well, not feeling safety

above a good balance, if I, uh, now I am feeling something new.

The following fourth session:KN: Ken, are you searching for yourself?Ken: Searching for myself? Well, ah, say, mm, I,

gradually, kind of found what a sense of safety with others is. That story reminds me of, uh, the moment that I was reunified with my family after a school trip in my sixth grade.

KN: Feeling your family safe after a school trip.Ken: Well, parents came to pick me up. Don’t you

know? Well, uh, then, I felt safe seeing my family. I thought that’s it.

KN: Yes, the family is your safe place.Ken: That way is what I am feeling right now.CoTh: How do you feel about yourself in here and

now?Ken: Well, how do I say? Not anxious. Mm, well,

anyway, I am sure I can feel better being here. I wonder, uh, I am not bad.

In multiple code theory terms that Mari pointed out that his speeches were “disfluent” and low in “clarity” and demanded him to raise the degree of the referential activity in a very direct way. The degree of the referential activity may be correlated with the bond to the object

Symbolized with a ‘hint’ of words such as “feeling safety” by “seeing somebody” that are abundant in “concreteness.” He felt safe by seeing his peers including Mari.

A memory of reunion with family; the group has changed into “a family that he can feel safe with.”

“Sense of groupness” as shared in the third session

Arisa: Yes. I was imagining that the atmosphere or the balance of this group would change if anyone of this group was put out of here.

Ken: Nobody changed the chairs’ places, right? I feel the circle has become smaller. Then, uh, well, it will make me safe. Settled down, yes, settled down. I think I feel settled down. This ring settles me down.

Hideki: Unlike other people, I feel somewhat anxious in this third session…I heard the people around me say they are getting safe little by little. I began to be conscious of what other people are like, and I turned less and less anxious.

Jun: My consciousness was far away, but for you guys I was sitting within on a ring. Well, yes, I felt that it was good but I was sorry that I was far away… Ah, I am the most delighted that everyone placed me in your ring.

The group entity is expressed with metaphors such as “circle” and “ring.” (cf. “wall” “shell” for individual boundary)

Everyone is thought to have his psychological space of the self and tries to ensure it by means of modulating it in the relationships with others, groups, and other psychological spaces.

When the group members get closer to each other, they form interpersonal circles for referential process.

It is thought that the working patterns in the group are represented in each of the group members in this way.

Mirror reaction (Foulkes, 1973) “refers to a patient in the group seeing himself or herself reflected in the behavior of another patient and learning about him or herself by seeing the reflection.” (Pinney, 1994) a “mirror” patient evokes in another patient strong sensory somatic reactions that are connected to the hidden or dissociated emotions. In the beginning the patient believes that he is frustrated by the “mirror” patient, but later he finds that the frustration was arising from inside of him. Thus the mirror patient can operate as a concrete image for the patient’s feared emotions and they get connected.

Two types of change of relationships; “gradual” type and “sudden” type (“invisible” or “implicit”, “little by little” versus “explicit”)

The two are continuous and influence each other; the former causes the latter through “kindling.”

There are two channels for referential process in both therapist and patient; one channel is the referential process for oneself and the other is for the other members.

These two channels are inseparable.

External circle for referential process and internal referential process

An external object plays the role of the nonverbal symbolic (imagery) code that works for (internal) referential process.

Representation of member A and their working patterns

Referential process

The multiple code theory is very helpful to explicate the process and change mechanisms in group psychotherapy.

The function of an object in group that works as an image for the referential process will be interestingly examined because it may extend and elaborate the multiple code theory.

RA Scoring (in Japanese) for empirical studies; (1) change of individuals across sessions

(2) change of group across sessions (3) interaction with each other within a

sessionAnalysis of speeches at a critical point or a

specific episodeCombined analysis of speech and nonverbal

behavior

THANK YOU ALL!SEE YOU SOON!