Short-term focused group-analytic psychotherapy (SFGAP): An integrative approach to change based on research

A short definition

SFGAP is a broad-based clinical approach that aims to relieve mental suffering, work towards resolving internal conflicts, and/or change dysfunctional behaviour. Patients suited for STGAP usually have circumscribed problems, and a moderate to high level of personality organization (Kernberg, 1980; Caligor and Clarkin, 2010). A treatment focus is established ahead of therapy, usually consisting of symptoms and central dysfunctional relational patterns. When these are activated in the interactions between the group participants, the therapist and the group are enabled to work more intensively with them in the here-and-now mode. The goal is to initiate a change process in each patient that can continue after termination. The therapy takes place in a closed group where all group members start and end at the same time. The group has seven to eight patients and one to two conductors (therapists) and consists of 20 weekly sessions, each session lasting for 90 minutes.

The theoretical foundation draws on group-analytic and psychoanalytic theories, especially Foulkes’ ideas of the group-as-a-whole, clearly summarized by Pines (1994). In addition, object relations theory (Kernberg, 1975a) and a structural evaluation of personality organization have a central position in the therapy (Kernberg, 1984; Caligor and Clarkin, 2010; Caligor, Kernberg, Clarkin et al., 2018).

Theoretical basis for SFGAP

Psychoanalytic theories constitute a basis for GAP. Foulkes was strongly influenced by social psychology and sociology through his contact with people representing what was later to become the Frankfurt school, and not least by his friendship with the sociologist Norbert Elias (Foulkes, 1942). While Foulkes himself was trained in ego-psychology, later group-analysts have put more weight on self-psychology, object-relations theory and interpersonal theory (Pines, 1996a, 1996b; Brown, 1994; James, 1994). These theories underline the person’s individual development, the Self, the need for relationships and to be recognized. They complement the classical psychoanalytic theories in which intrapsychic conflicts and defence mechanisms are central. Other group analysts have also made important contributions to the extension and development of group analytic theory and practice, for example Nitsun (2015), Schlapobersky (2016) and Behr (2005).

Although several psychoanalytic theories are represented in SFGAP, I especially value Kernberg’s object relations theory, as he tries to integrate ideas of psychoanalytic drive, structural, object-relations and self-theory (Kernberg, 1975b, 1980, 1984). His initial theories of how personality organization (PO) can be dimensionally assessed into neurotic, borderline and psychotic PO based on identity, maturity of defence mechanisms and the presence of reality testing, originated with his work on serious personality disorders. Later these theories have been developed further into a dimensional system for evaluating PO in general, based on assessment of a selection of structural elements of personality (Caligor, Kernberg, Clarkin et al., 2018).

Kernberg’s object relations theory explains how a person develops in relation to early significant others and gradually builds an internal world of representations that influence self-perception, attachment style, relational capacity, cognition, affect tolerance/control and overt behaviour. The theory encompasses the patients’ resources, psychopathology, dysfunctional behaviour and how aspects of the internal world appear as transference-counter transference reactions, both in the initial interviews and the group situation. SFGAP shares Foulkes’ understanding of the group-as-a-whole, as a gestalt comprised of all its members, and constituting more than the sum of what each member represents. Foulkes saw the individual as a social being and described how he/she is formed by social-cultural heritage, which each one brings into the group (foundation-matrix). In addition, the group develops its own history through multilateral interactions and communication between members (dynamic matrix). Further, SFGAP like long-term GAP, carries the ideas that all communications and interactions in the group are transpersonal and affect each individual differently, on a conscious or unconscious level. In a reciprocal way each individual will influence the other members and the group. Thus, both individuals and the group-as-a-whole have a marked impact via unconscious or conscious processes. These may be referred to as the personal and the social unconscious (Thygesen and Aagaard, 2002; Hopper, 2003) and constitute forces which are understood as signs of a ‘psychological causality’.

SFGAP maintains that constructive change processes can be triggered within a limited time, provided that patients are properly prepared for the therapy, and that they fulfil certain criteria, for example an established treatment focus and a certain level of PO.

Clinical experience and research evidence has demonstrated that patients suitable for SFGAP should be selected based on a thorough evaluation, which may take from three to five sessions.

What should be evaluated?

The following factors are important in the initial evaluation: the formulation of a treatment focus which should be linked to a psychodynamic case formulation. Further, it is necessary to assess a set of personality domains (structural elements of personality), like for example identity, object-relations, aggression (tolerance and control), defence mechanisms (maturity), moral standards, degree of pathological narcissism, attachment style, ability to mentalize and sense of reality. They overlap, but the first six seen together would constitute a profile that gives the therapist a dimensional view of the level of personality organization (PO), and give leads for planning treatment strategies in a psychodynamic therapy. The initial evaluation also includes a clinical diagnosis. Finally, I routinely include a self-report of the patient’s interpersonal problems, based on the Inventory of Interpersonal Problems (IIP-circumplex; Alden, Wiggins and Pincus, 1990). The patients rate themselves on 64 items of interpersonal problems on a scale from zero to four: things they find it difficult to do or things they do too much in relations to others. The profile indicates how they see themselves compared to others within the eight subscales of dominance, intrusiveness, over- nurturance, exploitability, non-assertiveness, social avoidance, coldness and vindictiveness.

How do we evaluate?

All relevant information can be collected through clinical and psychodynamic interviews with emphasis on actual complaints and problems, when and how mental disorders started and developed. In addition, the patients’ developmental history, personality description and information on close relationships over the years are important. Potential patterns of transference-countertransference can often be elicited from the patient’s description of close relationships, but I also like to include a psychodynamic section in the interviews, trying to tune in to and explore aspects of ‘distortions’ and test out hypotheses about connections between ‘there-and-then’ and ‘here-and-now’. During this procedure the patient’s ability to observe him/herself, to reflect on psychological connections and to mentalize, can be evaluated.

Agreement on treatment focus

The patient’s problems should be defined within a treatment focus which the patient and the therapist agree upon. This focus may consist of one or more dysfunctional interpersonal patterns which constitute or is related to the patient’s main symptoms and problems. This pattern should also be related to a psychodynamic case formulation which is a hypothesis linking points of vulnerability in the personality, stressors and clinical resultants manifested as interpersonal, relational problems and symptoms (Cabaniss, 2013). The IIP-profile should also be included in the discussion. It is based on the patient’s conscious perception of him/herself and does not fully reflect the patient’s ‘true’ relational world, which also consists of repressed or split-off aspects the person may only vaguely be aware of. The benefit of taking what the patient experiences as problematic as a point of departure, is that the profile often reveals unwanted (ego-dystonic) patterns the patient may want to change. Information from three different sources: IIP-profile, clinical interviews and perceptions from personal meetings with the patient offer the therapist a good basis for formulating a psychodynamic case story (hypothesis), as well as a focus for therapy that can be discussed with the patient. Taken together and compared with information from the interviews, the profile may point towards hypotheses about how unconscious self- and object-representations are organized and emotionally coloured. Moreover, it offers another opportunity for testing the patient’s ability to mentalize and reflect on connections/discrepancies that appear in the material.

Focus can also be one or more internal conflicts, for example between autonomy and dependency, or a ‘symptom complex’ like an eating disorder (Tasca et al., 2006) or pathological grief (Piper et al., 2001). Patients with mild to moderate personality pathology and a tendency of acting out, may also be treated in time-limited groups. The problematic personality traits or a specific impulsive behaviour should in these cases have been identified and explored thoroughly as a potential threat to the therapy, eventually be selected as the focus for the treatment.

Level of personality organization

When possibilities for change are evaluated, an initial assessment of level of personality organization is essential, since the ability to change during time-limited therapy usually requires a certain ego-strength. Patients have to be able to endure the relatively structured framework of the therapy, which entails opening up early and disclosing vulnerable parts of themselves, taking feed-back from others, and focusing on work in the here-and-now.

Space does not permit an extensive survey of how the six domains mentioned above can be evaluated, so I will briefly sketch some of the areas that have to be covered by the clinical/psychodynamic interviews: Identity encompasses three dimensions: Capacity to invest in school/work/spare time, and how effective the person is, how important these areas are and how much satisfaction these activities entail. Representation (sense) of self, both how coherent it is and if there is a feeling of continuity over time. Is the patient able to give a clear, coherent picture of him/herself? Evaluation of Representation of others, implies asking the patient to choose the most important person in their life, and to describe that person in detail. Is the result a coherent, comprehensive, varied description of a living person, or does it consist only of single adjectives? Object relations are evaluated based on the number of friends cited, and the quality and stability of friendships. Information about romantic partnerships is especially important; whether there is intimacy and sex in combination, whether the patient is dependable and whether he/she has a tendency to drop friends and partners. Maturity of defences is determined by the presence of higher level defences like sublimation, humour and anticipation of stress and plans on how to handle it, all defences that lead to better coping and less rigidity of the personality. Lower level defences are characterized by a tendency to idealize/devaluate others, externalization, black and white thinking (splitting) and suspiciousness of the motives of others. Aggression can be directed towards the self, for example neglect of physical health, high risk behaviour or a tendency to self-mutilation. When aggression is directed towards others it may result in loss of temper; the patient feels bad when others succeed; the patient enjoys other people’s suffering or has a tendency to cause psychical or physical harm to others. Moral standards may be more or less important in directing a person’s actions. Some individuals may do immoral things if the chances of being caught are small. Others may be too strict towards themselves. Some may enjoy deceiving others and maybe even engage in criminal acts. Does the person usually feel guilt when he/she does something wrong, or only when caught in the act? Narcissism may be characterized by chronic conflicts and disruptions in intimate and social relationships, by having a sense of self that is highly dependent on admiration from others, by functioning below standard at work and/or having strong feelings of envy or being preoccupied with comparisons with others.

There are many ways of assessing PO (see next section).

I recommend clinicians who are less experienced in evaluating personality structure and PO to consult Caligor et al. (2018) who gives a more detailed description of five levels of personality organization: normal, neurotic, and high, middle and low level of borderline PO (it should be mentioned that borderline PO is a wider concept than the diagnosis Borderline Personality Disorder in DSM-5). Caligor also rates the different domains on a scale from one (normal) to five (severe pathology) and offers clinical anchors for the degree of PO. I consider that patients who score three or less (normal, neurotic or high borderline levels of PO) will most likely be suitable for treatment with SFGAP. However, this view is mainly built on my own reflections, having compared a number of detailed case stories of group patients, with the clinical anchors mentioned above. Future prospective and controlled studies are needed to give us the final answers. I would add that we, as professionals, also must use our clinical judgement and consider factors like patient–therapist match, the therapist’s experience and availability of supervision. Caligor et al.’s system is a clinical version of the Structured Interview for Personality Organization (STIPO-R; Clarkin, Caligor, Stern et al., 2016). The interview and a scoring sheet are available at http://www.borderlinedisorders.com.

It is also possible to use other structured interviews or standardized questionnaires for diagnosing the level of personality organization, like DSM-5, section III (American Psychiatric Association, 2013), OPD-2 (OPD Task Force, 2008) and PDM-2 (Linguiardi and McWilliams, 2017. This is good since therapists may vary according to training, what kind of patients they work with, evaluation routines at their work place or personal preferences.

Motivation

The patient must both be willing to and have the ability to start a change within a short span of time. In this respect it is a positive sign if the patients are inspired during the interviews, for example by showing an increased interest in self exploration and constructive use of cues from the therapist.

Final instructions

The therapist should inform the patient about what to expect in the group and the rationale for choice of therapy. It is also important to exchange mutual expectations, including the patient’s negative expectations and ambivalence towards the therapy. Raise the patient’s expectations of a positive outcome by referring to positive experiences with groups, including results from research. Finally, a contract between the patient and the therapist is established, including rules such as the importance of informing ahead about planned absences and maintaining confidentiality outside of the group concerning what is learned about other group members.

Personal background

Dorothy had been raised as the fourth of eight children, in a large, but impoverished household. Her mother was an anxious person who worried about almost everything and had also suffered from episodic depressions most of her life. Her father was a strict, silent, hardworking man prone to sudden and unexpected outbursts of anger, and most of the time the patient was afraid of him.

Current picture

She has an unstable self-esteem and easily feels let down by her husband, whom she describes as controlling and dominating. She frequently becomes irritated and angry with him, but reacts mostly by feeling guilt and dismay. She can occasionally shake her children a bit roughly if they make too much noise or quarrel, but at school she usually succeeds in swallowing her irritation towards colleagues and students. Occasionally, however, she may give hurtful comments, and also feel strong envy towards some colleagues whom she considers to be the favourites of the head master. She frequently experiences headaches and neck/shoulder pain.

Diagnosis

After evaluation Dorothy was diagnosed with a recurrent depressive disorder. She also had some somatoform symptoms and personality pathology, but not a personality disorder. In her IIP-C profile she described herself as more distant and avoidant, but also more submissive, exploitable and overly nurturant, than others.

Representational world

The information on specific traits in her significant others and the character of her interpersonal disturbances, may feed a hypothesis of an inner world with self- and object-representations characterized by lack of positive confirmation, anxiety, and poorly controlled anger, which colours her perceptions of herself and others. The internal state may have manifested itself in a specific object choice (for example her husband) or in character traits or behaviours that ‘protect her’ from feared rejection from others, for example by social avoidance or by being overly controlled. This behaviour is partially irrational and motivated more by her internal world, than by who the other person actually is.

Level of personality organization

The different structural elements were covered in the evaluation interviews. She had a wobbly sense of self, needed a lot of confirmation from others in her job and easily felt hurt and neglected. She also had some difficulties in giving a detailed picture of her husband and children. There were also some problems of intimacy and sexual satisfaction. Her anger could sometimes frighten her, but she was able to control it most of the time, except under stress, when she also could lose control, and was more prone to black/white thinking, denial and projection. Alternatively, she could become self-derogatory and blame herself to a degree that was out of proportion with what actually had happened. Her moral standards seemed rather good, and she usually felt guilty after hurting the children, but she never apologized. Her envy and a need of support and admiration indicated presence of narcissistic problems.

She was evaluated to have a high level of neurotic PO, with an average score of 2.5, i.e. that she was within the range that most likely could benefit from SFGAP.

Treatment focus

After a thorough exploration and discussion of all available information, she and the therapist agreed upon the following focus of her therapy: she should challenge and explore her own avoidance and distancing to others, and reflect on how these manoeuvres protected her own inner world and also try to explore to what degree they maintained dysfunctional relationships to others. Finally, she was given the behavioural task of disclosing more of her feelings to others. This should be done at least once every second session, and should involve both her wishes for closeness and intimacy, but also her feelings of distress and being let down because others had violated her private boundaries.

Work in the interpersonal phase

The group was early in the interpersonal phase when someone commented that Dorothy seemed to distance herself and shut off from contact with the other group members. What had happened ahead of that? She answers rather irritably, after some hesitation, that Steve, a young man who could often be rather intrusive and not so empathetic (his therapy focus was among other things, to work specifically with these aspects), had interrupted her in the middle of a sentence. She had just told about her husband who let her down by leaving all the responsibility for their children and their home to her. Steve was strongly provoked by her comment, especially that she maintained that he had been impolite when he addressed her. Henry, who had a problematic relationship to aggression and therefore easily became submissive, exploitable and/or avoidant in conflicts, immediately started to explain that Steve had actually not interrupted, but had been very eager to tell the group about something positive which he had experienced at work.

The example offers a typical sequence from a group where three patients in a row, have ‘commented on’ each other and at the same time disclosed aspects of their slightly dysfunctional, relational patterns (personality aspects) they had agreed on/chosen to work with in the group.

Intervention-group work

The therapist who for a while had quietly observed the process in the group, had noted how Steve brushed Dorothy away when she talked about being let down by her husband. He also noticed how her slightly aggressive response triggered Henry and made him enter the arena in order to deny and cover up signs of a conflict. It struck him that Steve himself was left and let down by his father as a child, when father met another woman and moved from the town where they lived, and that Steve since then had denied that this had been difficult for him. Further, the therapist wondered if Dorothy’s story created imbalance in his internal world, where painful feelings connected to self- and object-representation that tied father and Steve together early were repressed. Subsequently, he decided to look closer at this sequence. He knew well that the persons involved might not be aware that parts of their treatment foci have been activated, but he felt that the group was safe enough and ready to work on these issues. The intervention may simply be: ‘Let’s stop for a while. I think something important is happening here!’ All group members are then invited to explore the sequence which has affected everyone (the transpersonal perspective). Through this intervention, attention is directed from the manifest level of the sequence of interactions, to the dynamic determinants of the relational patterns (latent level). The sequence can be recapitulated and potentially offers an arena for learning and for having a ‘corrective emotional experience’ (Palvarini, 2010). By taking the incident that took place here-and-now as a point of departure, by tuning down the negative aspects of the squabble and defining them as communicational attempts, it may be possible to stimulate the members of the group to explore and reflect. And if more or less stereotypic responses from those involved are met with warmth, interest and understanding, new learning may take place, as opposed to escalation of a conflict which leads to ‘retraumatization’ for those involved.

At the start of the termination phase (two to three sessions) the therapist may have to remind the group that the end is approaching. Patients may feel that they have not gotten enough in the therapy, like in their lives. Feelings connected to separation and loss may be shared. Some may look forward to spending their Thursday afternoons (i.e. their therapy sessions for the past 18 weeks) differently. Anxiety about not being able to manage on their own is activated, and the therapy process is evaluated, important moments are recapitulated and changes and residual problems are summed up. In addition, the resources of each patient, as well as old and potentially new relationships and activities are brought up and discussed as meaningful resources to spend more time with, when the treatment is over.

What happened to Dorothy?

Several of her dysfunctional interpersonal strategies were activated and explored in the group during therapy and new ways of relating were tried out. After termination she rated herself as less avoidant, less exploitable and more assertive (less submissive) than before therapy, and she had gradually become more able to set limits for the children in a more constructive way. When she was followed-up two and a half years later, she had improved further. She had negotiated with her husband that he should get a job closer to home, and she had fewer disciplinary problems with her students. She also had less pain in her neck/shoulders and had not experienced further depressive episodes.