Resting on Common Ground: Integrating Psychodynamic Group Therapy with Other Models
Mark Sorensen, PhD, CGP 

During its history, AGPA has struggled with a tension between loyalty to its psychodynamic roots and a curiousity about learning from other approaches to group work. In my journey as a group psychotherapist, my first love has been the psychodynamic model. However, while remaining appreciative of all it had to offer, over time I experimented with other theoretical approaches that were at certain times with certain clients superior in their efficacy compared to psychodynamic psychotherapy. I have found that opening up to different perspectives and integrating them into my psychodynamic framework has enhanced my work as a therapist. I wanted to explore how some senior psychodynamically-oriented group therapists have come to integrate different theoretical models into their treatment approaches. I asked Ken Porter, MD, CGP and Eleanor Counselman, EdD, FAGPA, CGP to comment on their experiences with integrating spiritually-oriented psychotherapy and Cognitive Behavioral Therapy (CBT) with psychodynamically oriented group psychotherapy. Dr. Porter is the Director of Psychiatry for the Center for Spirituality and Psychotherapy, a program of The National Institute for the Psychotherapies in New York City. Dr. Counselman is an Assistant Clinical Professor in Psychology in the Psychiatry Department at Harvard Medical School and the editor of The Group Circle.

How did it happen that you became so influenced by another approach that you felt compelled to integrate it into your work?

KP: About 15 years ago I developed a minor heart ailment and after I pursued Western remedies without any success I began to explore alternative medicine, including meditation. As I did it began to have beneficial effects for me psychologically and spiritually, and then I began to bring it into my work with my patients. I have been meditating for 15 years and am currently in training to be a leader of Buddhist meditation. But it all began as an effort to help my heart.

EC: There were two major influences. I became interested in working with clients with learning disabilities and when doing that you quickly find out that psychodynamic therapy is often not helpful. Instead, structured learning experiences are called for. Also, I took a course with Herbert Benson, MD at the Beth Israel Hospital Mind-Body Clinic in Boston. I felt like I had walked through a door into a whole other world because they don’t do psychodynamic work there but they do everything in groups. There was a lot of exposure to CBT and their research substantiated clear benefits of this approach for their clients. That got me paying attention to how our thinking influences our behavior, even in the absence of neurotic conflict.

How do you work with the conflicts between the models?

KP: The two approaches are quite compatible as long as one doesn’t define the psychodynamic model too narrowly. In the spiritually-oriented model there are two levels of self--the neurotic or conflicted self and the truer self that underlies it. In that model the presence of unhappiness and suffering comes not from conflict within the self as with the psychodynamic model but comes from a lack of contact with the deeper levels of the true self. The next level of disagreement has to do with therapeutic healing. In the psychodynamic model, there is an emphasis on experiencing and understanding negative affects and modifying the superego. In the spiritually-oriented model there is an emphasis on letting go of affect and emotions as well as developing an understanding of them. Also, the possibility is held out of the abolition of the superego, not just the modification of it. The final difference has to do with therapeutic technique in that the psychodynamic model emphasizes the therapist doing work on helping the patient to heal and the spiritually-oriented model uses the postulate from existential psychoanalysis that the fundamental aspect is “presence”--fully being with the client rather than trying to fix the client or do something to the client.

EC: I do find that my CBT training has helped me to listen more to the patient’s strengths and the solutions they’ve come up with, as well as assess the patient’s readiness to change, which a psychodynamically-oriented approach doesn’t focus on as much. However, I don’t believe there is a basic conflict between these models. I think the psychodynamic and CBT models work synergistically. I see it as a positive spiral between thinking, feeling and behaving. A client can have an insight, perhaps linking past with present, and that leads to behavior change. The behavior change can have its own positive effect on the person and can ripple back and something else bubbles up that needs to be understood.
In my groups for public speaking anxiety, as you teach people techniques for calming their anxiety they can stop being so focused on how frightened they are and begin to have a positive experience. Then you can get curious with them about what it means to allow themselves that positive experience as well as how they came to be so inhibited. It’s important to get to the early experiences that squashed some of their natural impulses towards exhibition.

How does integrating two different models work to your advantage in your group work?

EC: I find that for specific problems, like public speaking anxiety, an integrative model in a group works really well. On the one hand, there is the teaching of the various CBT techniques but the piece that really pulls it all together is when you explore the meaning of their fear. For example, in one group, during a relaxation and imagery exercise, one group member had a powerful image come to him. This was explored by the group and led to an understanding of how he came to project the people who shamed him as a child onto his current relationships. The group was very supportive and empathic in their responses, which was crucial to his management of his anxiety. Then we shifted back to the CBT and recognized that image as a negative automatic thought that could be counteracted.

KP: One of the advantages to an integrated model is that if the therapist has done spiritual work it enhances our capacity for empathy and compassion enormously. In addition, meditation is superb training for a psychotherapist because the emphasis on being objective about emotions helps in handling countertransference—both the hate and the love countertransference. For the patients it operates the same way. When bringing a spiritual perspective into a group what you see is that the group members develop an enhanced capacity to be empathic and helpful to other members of the group without denying their own basic emotional reactions. In my experience what happens is that people feel safer in group, go to deeper levels more quickly and while their conflicts still emerge there is less acting out . To put it simply, there is more love in the room and there is more healing that occurs more quickly.

Has it been difficult to allow yourself to become known to your psychodynamic colleagues as someone who is integrating other models into your work?

EC: Initially I had some concern about being viewed as a dilettante; ”oh, she’s done a little bit of this, and a little bit of that”. But I was so fascinated and excited by the integration of CBT work with my psychodynamic way of thinking that in the end I didn’t care what people thought. This is what I’m doing and who I am, and I know this approach works.

KP: In the first years I felt probably the way a gay therapist felt 15 years ago and may still feel. I felt awkward and embarrassed. I felt that if I revealed my spiritual orientation my colleagues would think less of me; they would think of me as a kook or a new age wacko. It was something I kept to myself and talked about with a very few other therapists that I knew shared that orientation. In the last 5-10 years there has been a completely different climate in the whole country where people have become more interested in religion and spirituality and that has permeated into our profession. What has happened is that more people have felt comfortable about speaking up about this orientation and as that happens it has become easier to speak one’s mind. What I find is that my psychodynamic colleagues are interested and see this as something they can learn from.

This article was published in the October/November 2001 issue of The Group Solution.