Integrative Psychotherapy in Action

Richard G. Erskine

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429915024
• Subtopic: History & Theory in Psychology
• Index: Psychology

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.

1

Introduction

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.

The first obvious break in the monolithic structure of psychoanalytic and neo-psychoanalytic dominance occurred in the 1940s. Perhaps we should say “breaks,” for there were suddenly not one but two major alternatives to psychoanalytic thinking: humanistic psychology, articulated by Abraham Maslow (1954,1962) and Carl Rogers (1942, 1951), and the behavioral approach to therapy that grew out of the experimental work of Ivan Pavlov (1927) and B. F. Skinner (1938,1953) and the learning theory of O. Hobart Mowrer (1950).

Behaviorism has traditionally involved itself in demonstrating that universal laws govern the behavior of all organisms, from microbe to man. Understanding these laws would allow the creation of a technology of behavior, by means of which all undesirable behaviors could be eliminated. The early behaviorists were explicitly and vehemently uninterested in “thoughts” or “motives” or “emotions” as such. If it couldn’t be measured, or somehow observed by someone else, then it was nonexistent—or at least of no real importance. “Don’t talk about being depressed,” said the behaviorist, “tell me what you do when you’re depressed and I’ll help you to find a way to stop doing that and start doing something else instead.” When the behavior changes, went the theory, the internal experience (whatever that is) will also change. The behavioral approach to therapy (Bandura, 1969; Dollard & Miller, 1950) considered many of the concepts developed by Freud—instincts, defense mechanisms, the unconscious, focusing on the historical “why”—to be irrelevant. What mattered were the contingencies that maintained a “problem” behavior and what the new behavior would be. The model was clear and logical. Moreover, it was research-based: Behaviorists could prove that their methods worked. Study after study claimed dramatic changes in client’s behavior in a variety of problems ranging from agoraphobia to voyeurism.

In contrast to the relatively mechanical approach of the behaviorists, the humanistic psychology movement focused on the uniquely human attributes of the individual. Human beings are more than machines, are qualitatively different from rats or pigeons. Yet humans are not, as Freud would have us believe, driven relentlessly by sexual and aggressive urges, helpless to do more than make the best of a whirling chaos of animal instincts. Abraham Maslow saw men and women as self-actualizing creatures, motivated by the need to become the best that we can be. The basic premise of humanistic psychology is that people must be understood in the context of their unique humanness. Health, growth, and fulfillment, rather than the temporary surcease of drives or the achievement of reward, are the human goals; the quest for one’s own potentiality is the human birthright. People are born healthy and, given good growth conditions, will stay that way. Things go awry and dis-ease occurs when those growth conditions are not met. Carl Rogers (1951) applied these humanistic concepts in his formulation of client-centered therapy, in which cure is a matter of restoring the conditions of growth—understanding, unconditional acceptance, genuineness of relationship. Given these necessary conditions, people will naturally and automatically begin to respond in healthy ways.

Maslow’s and Rogers’s ideas were exciting to a new generation of psychologists, tired of the limitations of psychoanalysis and behaviorism. Their position was simple, direct, optimistic. It offered hope. Moreover, Rogers offered a clear and understandable set of directions for actually working with clients. Carl Rogers’s non-directive approach—client-centered therapy—changed the face of psychotherapy forever. Nearly every psychiatrist, psychologist, counselor, and social worker now practicing, of whatever orientation, began his or her training by learning basic active-listening techniques that grew directly out of Rogers’s work.

Thus the stage was set for the Great Psychological Debate of the 1950s (Rogers & Skinner, 1956), a debate that still rages among psychologists (albeit somewhat more quietly now). It was called humanism versus behaviorism, and it pitted the people-are-unique-and-unquantifiable group against the behavior-can-be-measured-and-predicted-and-controlled group. The softheads against the hard-noses. The poets against the pragmatists. The development of the nondirective and behaviorist schools had another effect as well: It was the breach in the dam through which eventually poured an ocean of alternative theories and therapeutic approaches. The admixture of ideas from Freud and his colleagues, from Skinner and the behaviorists, and from the client-centered school begun by Rogers provided a fertile ground for the growth of therapeutic practice. And it is at this point that our story, until now somewhat academic and removed, becomes directly and immediately related to the ideas to be presented in this book. For three of the newer theorists—each emerging from and trained in the discipline of psychoanalysis, yet all inevitably affected by the climate of the Great Psychological Debate—contributed two specific psychotherapeutic models upon which integrative psychotherapy rests. These theorists were Frederick and Laura Perls and Eric Berne.

Perls and Gestalt Therapy

Frederick and Laura Perls’s contribution is known as Gestalt therapy, taking its name and underlying ideas from the Gestalt psychology of Wertheimer, Kohler, and Koffka (Perls, 1947; Perls, Hefferline, & Goodman, 1951). Gestalt psychology is concerned with the experiencing organism’s tendency to perceive and remember wholes rather than collections of parts. The tendency extends to the “closing” of perceptions or experiences in memory, even though the actual stimuli may not form a completed whole. Four unjoined lines, arranged in a roughly square pattern, will be perceived as a square or a box. A story will be recalled with missing elements neatly filled in. So it is, said Perls, with our emotional experiences. The normal and natural human pattern is to complete an experience and with completion comes a sense of wholeness and of being finished. We are then free to move on to the next thing that claims our attention.

Primary and Secondary Cestalts

A need is felt, it is met; the whole is completed and we are done with it. We do not tolerate incompletion, and if the environment fails to provide us with the means for completing our experiences (our gestalts), we will fill them in artificially—for example, with substitute satisfactions, feelings, and fantasies. Such artificial closure results in a “secondary gestalt” in which the self-generated closure brings short-term relief from tension, but the individual must inevitably repeat the pattern because the closure is not one that allows him or her to move on to deal with the next natural and organically occurring experience (L. Perls, 1978a). Over time, these secondary gestalts tend to rigidify and become fixed patterns of perceiving, of thinking, of feeling, and of behaving. In part, the “fixed” perspective serves to keep old desires, unmet needs, and uncomfortable experiences out of present awareness. The fixed gestalt does not allow for full contact here and now between the current needs of the person and the people or objects in the environment.

As an example, consider Gordon, an obese 36-year-old man. In childhood, Gordon tended to be slow and clumsy and had trouble making friends. He often came home from school in tears because of the way his classmates alternately ignored or tormented him. His mother’s response was always the same: “Don’t feel so bad; it will be all right. Let’s sit down and have a little snack together.” Gradually, Gordon learned to stifle his natural craving for peer contact, his need to grow into healthy interdependence with others, by stuffing down food and leaning on Mother for comfort. Today, whenever Gordon finds himself feeling “frustrated” (the only word he can find to identify that archaic, formless need for social contact), he turns to food and/or the maternal comfort that his wife obediently provides. Indeed, he truly experiences and identifies his contact need at such times as a feeling of physical hunger. For the moment, food and the soothing presence of his wife help; the “hunger” is satisfied. But the discomfort always returns, as mysterious and as confusing as ever.

Like the thirsty man who puts a pebble in his mouth because he has no water, the temporary relief that Gordon gets from eating must eventually give way to an even greater sensation of need. The pebble serves as a secondary, artificial relief of the sensation of thirst, but the primary need for water remains, even though the man is less consciously aware of it. In a similar way, Gordon has set up an artificial means of dealing with his unmet psychological and social needs, finding temporary relief or distraction while continuing to repeat what is unfinished from the past.

The Structure of Personality

In addition to the concepts of primary and secondary gestalts, Gestalt therapy continues to draw upon a number of psychoanalytic ideas, particularly the concepts of “ego” and “id” (Freud, 1923/1961) and the notion of defense mechanisms and how they are manifested in contact interruptions (Perls, Hefferline, & Goodman, 1951). The ego is defined as the identifying and alienating aspect of self. It is the sense of “me” or “not me.” It internalizes and discriminates and is the organizing factor whereby people interact with the external world. As needs, appetites, and desires of the organism—the collection of urges that psychoanalysts refer to as “id”—come into awareness, it is the identification with or alienation from these sensations that in part constitutes the ego. When a person knows that he or she is hungry, or wants to sit down, this awareness of bodily sensations in part defines who he or she is at that moment—ego. The constant shuttling back and forth between awareness of internal experience and awareness of the environment, along with accepting or rejecting what the environment offers, is the essence of ego. Healthy ego, then, is a process, a verb rather than a noun. It is ongoing movement. It is a shifting, a changing, an existing in the endless moment of “now.” It evaluates what the current environment presents and assesses internal sensations, bringing the internal and the external together in a never-ending series of experiences.

Although the notions of ego and id are basic to Gestalt therapy, the other structural division of psychoanalysis—the superego—is not. Nor is Freud’s notion of the unconscious, a reservoir of memories barred from conscious awareness, useful to Gestalt therapists. Instead, Gestalt therapy (Perls, 1947) emphasizes how introjection and repression—basic defense mechanisms—serve as interruptions to contact. In an attempt to cope with needs not being met, and with a lack of needed contact with people, we suppress our awareness of both internal and external events. The result is that we are then unable to be in full contact with ourselves or with what is going on around us. This loss of awareness of needs, feelings, experiences, and memories is repression—a defensive, active “forgetting” or shutting down of some part of our thinking and feeling. Repression always involves a corresponding muscular inhibition within the body as an active means of maintaining distraction from full awareness.

As a consequence of active repression, the possibility exists for introjection, an unaware defensive internalization of elements of the personality of other people. With introjection, we metaphorically “swallow whole” that which is presented to us by others; we are unable to integrate it so that it becomes a part of the responsive, changeable, ongoing self. It sits within the ego like an indigestible lump, neither contacting nor contactable.

Introjection is only one of a set of contact-interrupting defenses that maintain repression. A second is projection, wherein a part of the self—thoughts, motivations, feelings—is perceived as being in another person. The projecting person is not conscious that the sensations are within himself; he responds, not to the real other, but to his own projected images. Retroflection is the holding back of action that could be expressed outwardly, as when we carry on an internal dialogue with ourselves rather than interacting with the outside world; or we tighten muscles instead of screaming or hitting. Deflection, the lessening of the significance of internal sensations or feelings and screening out or fending off attempts at contact that others may make, is also a way in which we interrupt contact. And finally, confluence—losing our boundaries, experiencing self and other as one unit—destroys contact because self and other are now fused and there is no longer any “other” and/or a distinct self with whom to be in touch. Contact interruptions or defense mechanisms maintain repression: The person using them represses his or her awareness of the real (or potential) interaction between him- or herself and the external world, and maintains the belief that his or her particular way of not making contact is, in fact, the only way to interact in that situation. Dealing with contact interruptions, often through the medium of the therapist’s own openness to contact, and restoring awareness of both the internal and the external world, are hallmarks of integrative psychotherapy.

Berne and Transactional Analysis

In developing the theory of Transactional Analysis, Eric Berne— like the Gestalt therapists—used the definition of ego as a basic element. Berne, however, viewed the ego in a different way than did the Perlses and their students: while the Gestaltists considered the ego as an indivisible and continually emerging process, Berne described it as consisting of various clusters or states, each with complete and coherent patterns of thoughts, feelings, and behaviors. Berne expanded on the ideas of psychoanalyst Paul Federn (1953), who reported that his clients seemed to have distinctly different egos at various times during their therapy. At times, for example, clients would have full awareness of what was occurring both inside and outside their organism in a way appropriate to their developmental age. This contact function of the ego accounts for and integrates what is occurring moment by moment, internally and externally. It also integrates past experiences and their resulting effects, along with the psychological influence of other significant people. Berne colloquially referred to the neopsychic state of the ego as the “Adult.” The Adult ego state consists of one’s current age-appropriate motor behavior; one’s emotional, cognitive, and moral development; one’s ability to be creative; and one’s full contactful capacity for engagement in meaningful relationships.

The here and now psychological state of the ego (neopsyche or Adult) can be contrasted with an archaic ego state, consisting of encapsulations of the thoughts, feelings, and behaviors of earlier developmental stages. These archaic ego states are analogous to a collection of fixed gestalts (in Perls’s terminology) in that these childlike states of the ego are “fixated” or stuck in the past. This aspect of ego perceives the external world, as well as internal needs and sensations, as the person did in an earlier developmental stage. Although the person may appear to be relating to current reality, he or she is actually experiencing what is happening with the cognitive, emotional, or behavioral capacities of a child. He or she has regressed, internally, to the point in development at which an unresolved trauma or confusion originally occurred. Berne colloquially referred to this aspect of the ego as the “Child” ego state.

It should be noted that using the term ego state in the singular is somewhat misleading. A child develops through a number of phases and stages—as Jean Piaget (Phillips, 1969), Erik Erikson (1950), Margaret Mahler (1968,1975), and others have described—and at any of these phases and stages there may be repression and fixation. Under the influence of one set of stressors, we may think and feel and act much as we did when we were six years old; under another, we may regress to an unresolved adolescent problem or even back to early infancy.

In later psychotherapeutic work, Berne explored Federn’s observations that the constant psychic presence of parental figures influenced the behavior of many of his clients. This internalized ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Dedication Page
• Preface
• 1 Introduction
• 2 Conrad
• 3 Chris
• 4 Ben
• 5 Frankie
• 6 Robert
• 7 Emily
• 8 Sarah
• 9 Bill
• 10 Glenda
• 11 Charles
• 12 Jon
• Index
• About the Authors