The International Journal of Psychosocial Rehabilitation

Reference Group Focused Therapy:
A New Integrative Short-Term Social-Psychology Based Approach
 

 
Igor Salganik M.D.

 Peter Soifer M.D.

Sha’ar Menashe Mental Health Center, Mobile Post Hefer 37806, Israel
 
  
 
Citation:
Salganik I. & Soifer P. 
(2009). ‘Reference Group Focused Therapy – a New Integrative Short-Term Social-
Psychological Based Approach.
  International Journal of Psychosocial Rehabilitation. 14 (2),   15-24
           


Correspondence:
Igor Salganik
Sha’ar Menashe Mental Health Center
Mobile Post Hefer 38814
Israel
      


Abstract
In this paper we present a new psychotherapeutic approach - Reference Group Focused Therapy (RGFT). The most striking feature of this approach is that it takes into consideration  the entirety of person’s social environment expressed through the corresponding reference groups and person’s sub-cultural background as opposed to other psychotherapies. RGFT is based on a number of established social psychological theories as well as on social learning theory, object relation theory, attachment theory and other approaches. 

RGFT addresses external person’s reference groups (such as family, working place,  etc.) along with  his/her internalized groups. It belongs to short-term client-centered psycho-therapies and has already demonstrated its efficacy in different clinical entities such as phobias, OCD, eating disorders, adjustment disorder, somatization, anxiety disorder, panic attacks, and others. During the assessment phase of a treatment we use Trigger Event Analysis – a newly developed tool that enables understanding of person’s individual vulnerability and allows both the prediction of the future conflicts as well as finding more effective ways of avoiding or minimizing them.

The treatment itself focuses on studying the conflicts of both internal (between the internalized groups) and external (between internalized and external groups) origin.
One of the main goals of the treatment is to allow a patient to uncover the present (external groups) as well as historical (internalized groups) social influences thus promoting his/her individuation process along with amelioration of subjective distress. The article includes two case-reports illustrating the approach
.
Key Words:  Reference Group, social influence, social psychology, psychotherapy, conflict

        



Our mind is nothing but a bundle or collection of different perceptions, which succeed each other
 with an inconceivable rapidity, and are in a perpetual flux and movement."

 
David Hume. A Treatise of Human Nature. Book I, Part 4, Section 6 (“Of Personal Identity”)  1739 (published anonymously)

Introduction

Modern society is facing a dilemma.

On one hand statistics demonstrates a steady increase in stress-related disorders (Sutton. 2007), on another hand, though there is a common demand in quality of life improvement, society is not prepared to corresponding investments in both time and financial resources due to other prerogatives.  Psychotherapy, which is one of the most effective tools in coping with stress (Brody & Stuart, 1994; Jones et al., 1999;  Strain, 1995), has historically been transformed into an attribute associated with people who are well off financially, in some way not dissimilar to golf club or prestigious car (Austad, 1996). The wish to make psychotherapy more widespread, initiated development of short-term psychotherapies such as psychodynamic short-term treatments, cognitive-behavior therapy (CBT), interpersonal therapy (IPT), and others. All of these therapies share a dichotomistic view that distinguishes between an individual and his/her environment not seeing them as one undividable unity.

As a result, the problem that has been intrinsic with such therapies was an inevitable compromise in goal setting and a reductionist approach in their assessment of the human psyche. Social psychology with its emphasis on social influence has always accepted the view that a person should not be regarded outside the context of his/her social matrix (Myers, 2006). Yet, its subject was in general the explanation of normative social phenomena and not exploration of human psychopathology.

We introduce here a newly conceptualized psychotherapeutic approach based mostly on the elaborations of reference group theory and related concepts of social psychology  along with other conceptions such as learning theory, attachment theory, object relation theory , and others.  The approach is intended for  treatment of a Social Influence Related Disturbance (SIRD).
SIRD is defined here as any mental or psychosomatic disorder that was originated or co-contributed by either external social influence mediated by individuals or groups and / or their intrapsychic internalizations.

It’s apparent that this category does not introduce any new nosological entity per se, its purpose is solely the shifting of point of view into the direction of the implied impact of social influence.

A patient, for that purpose, is regarded as a member of a social group or a number of groups. The disorder is seen in a context of functional and structural group changes, the patient’s interactions with the group, as well as interactions between the groups’ internal representations among themselves and/or external groups.

RGFT
As stated before, RGFT deals with a spectrum of disorders associated with social influence.

It may be implied, that  these disorders (SIRD) originate from a psychological reaction to a stressor associated with influence caused by external or internalized  groups. This view is congruent with Reference Group Theory (Hyman ,1942;  Sherif, 1948;  Merton & Kitt, 1950; Deutsch & Gerhard, 1955) which looks at psychosocial stressor and maladaptive response to it  in context of person’s reference  groups (Hyman & Singer, 1968). We also adapt  here the concept of the internalized group firstly introduced by Turner (Turner, 1987, 1991 ) which is analogous to the object relations’ internal representation (Fairbairn, 1954; Guntrip, 1995).  Additionally, we hypothesize that derivation of the RG’s social influence is in the basic need for attachment similar to understanding of attachment theorists (Ainsworth et al., 1978; Bowlby, 1999)  and that this influence is mostly mediated by modeling as stated by Bandura (Bandura et al., 1989, 1999). In our elaboration we were influenced also by the conception of multiple selves (James, 1950; Assagioli, 2000; Stone & Stone, 1983; Stone & Winkelman, 1993).

Before discussing the therapeutic approach, we introduce a number of theoretical elaborations.
The  RGFT  basic assumptions are as follows:

1. Person’s behavior, emotions, and attitudes can be comprehended only within the context of his/her present and historical social matrix.

2. The reference groups differ in their impact on a person in accordance to the importance that he/she ascribes to those groups.

3. Person can be regarded as comprised of a “Primary Self” - a personality core that emerges prior to socialization (initiated by the begin of speech acquirement), his/her internal groups (Secondary Selves), and internalization of his/her subculture.

4. Social influence (mediated by the internal and external RGs)  is partly conscious and partly unconscious.

5. Much of the psychopathology developed after the begin of person’s socialization can be explained through the conflicts occurring among person’s internal groups (Secondary Selves) as well as through conflicts between the person’s internal (Secondary Selves) and external RGs and/or personality core (Primary Self)

Another important theoretical elaboration is Trigger Event Analysis (TEA) that has been described in details elsewhere (Salganik & Soifer, 2008). TEA divides all triggers leading to some kind of  mental breakdown into 6 categories: Status, Norms, Attachment, Threat, Routine, Energy. These triggers have either explicit or implicit social characteristics, which means that they are associated with patients’ RGs (either internal or external ones). The given context of mental deterioration leads to the conclusion that these triggers have to be regarded as negative triggers - events that precipitate deterioration in mental states.

TEA assumes that an individual reacts to all possible triggers in a for him/her unique and specific way. The same trigger that may have a profound impact upon one particular individual may leave another one totally unaffected. The personal sensitivity to specific triggers is categorized in exactly the same way as the triggers themselves. That means that each person will exhibit sensitivity (or lack of it) to such issues as changes in status, RG norms, attachments, threats, routine, and energy resources in a for him/her specific way. We call the corresponding personal sensitivities – Sensitivity Channels. For example, if a person is sensitive to changes in his /her status  and  the corresponding changes are imposed on him/her by the social environment, there will be a high probability for aversive mental response.

Figure I summarizes the described theoretical model:


Primary Self: is a psychical structure that develops prior to socialization. Socialization in the sense of RGFT overlaps greatly with the same term in social psychology and thus does not include the first two years of life prior to language acquisition and prior to the brain ability to internalize integrative aspects of the other object (or him/herself), including perception, cognition, emotion, and behavior.

Secondary Self: is a psychical structure that develops in a process of socialization. It represents the internal image and is a result of internalization of the corresponding RG (that could be a single person or a group of persons). Secondary Self comprises following characteristics (that in a way resemble a blue print of a corresponding person/group): perceptional, cognitional, emotional, and behavioral patterns.

Dictator Self: is a subtype of a Secondary Self which Reflective Self is tightly identified with. It is thus the most dominant among the Secondary Selves and influences greatly a person’s perceptional, emotional, cognitive, and behavioral pattern.

Reflective Self: is a psychical structure that represents a person’s autonomic ability to evaluate a given situation and to choose a corresponding adaptive response.

Subculture: is a source of a social influence upon a person that can not be inferred or deduced from any specific RG effect but is a result of an integrative impact of a certain social environment as a whole.
 
Defensive Shield: is a variety of mostly unconscious adaptive mechanisms that a person develops in order to diminish a negative impact on his/her Sensitivity Channels.

In addition, we summarize some novel aspects of our approach in comparison to other psychotherapies:
1. It takes into consideration an entirety of the patient’s RGs and not just their selected subgroup

2. Secondary Selves are typically associated with real persons or RGs which are charged with certain personal significance

3. Secondary Selves are interrelated in a hierarchical order where the Dictator Self secures to itself the highest rank among the Secondary Selves.

4. Much of psychopathology is being interpreted through the conflicts among  Secondary Selves themselves and between Secondary Selves and external RGs.

5. A new concept – Trigger Event Analysis  reflects the individual sensitivity regarding the  variety of possible psychosocial stresses.


RGFT  (therapeutic aspects)

Assumptions about the therapy:
1. Psychotherapy’s general goal is to facilitate patient’s adaptation to his/her specific society

2. Individuation is an utmost goal of RGFT and can be achieved by exploring person’s social influences and bringing them into consciousness

3. The treatment is client-centered, person is advised from the very beginning that he/she is the only one that actually knows and is in the position to cope with his/her problems and not the therapist. Any attempt on patient’s side to invite social influence from the therapist is explored and patient’s responsibility for resolving of his/her problem emphasized

4. The focus of the treatment is the investigation of “inversed” transference, e.g.  the impact of patient’s  internal groups on his/her attitudes and behavior – (“acting on behalf of internal groups”)

5. The treatment is “patient-driven”, the working topics and the termination of treatment are determined by a patient

Treatment Guidelines
Patient Selection Criteria

1. An analysis of the patient’s problem makes it feasible that there is a major issue associated with his external and/or internal RG’s which comprises one or all of the following:

•    Paucity of RG’s number

•    One or more of his/her RG’s has a pathogenic quality (exerts a profound  negative emotional impact -causes significant mental distress  upon a person. We assume, in the context of TEA, that this negative impact will be upon one or more vulnerable Sensitivity Channels)

•    One or more of his/her empathetic RG’s has undergone recent functional or structural changes (empathetic group is the one that exerts a profound positive emotional impact upon a person. Again, this influence will be mediated through the one or more Sensitivity Channels involved)

•    Existing conflict(s) between internalized groups themselves, and/or between internalized and external group(s), and/or any of the above with the primary self

 2.  A patient has to be cooperative with the therapy and to be able to comprehend its goals.


3. At assessment stage, an analysis of the internal and external RGs, that are relevant for a person should be performed.

It is crucial to evaluate whether the patient’s RGs play an important role in initiation of the present mental crisis.

Trigger Event Analysis (TEA) is performed - typical triggers for a patient identified. The triggers are evaluated against the relevant RGs. If triggers are associated with only a limited number of specific external RGs, then the problem is likely to be with those external groups – RGFT for external groups (RGFT ext.) is advised.  If triggers are more or less evenly distributed  among different external RGs – there is probably a problem with the patient him/herself. In this case, RGFT for internalized groups (RGFT int) is advised.

Therapeutic approach for the external RGs (RGFT ext) is handled elsewhere (Salganik & Soifer, 2008). It should be mentioned that though described in association with schizophrenic relapse, the paper conclusions may be as well generalized for other mental disorders associated with SIRD.  In this paper we describe a therapeutic approach relevant for the internal RGs (RGFT int).

4. Treatment stage in RGFT int. is based on a proprietary theoretical model and aims at enhancement of patient’s individuation and better awareness of social influences.


The RGFT int. Session:

Step One:  Deciding Which Secondary Self to Interview
•    Identify the issue, distress, problem, or Secondary Self the patient wants to focus on.

•    Moderator and person’s Reflective Self can co-decide which Secondary Self to begin with.

•    At the beginning of the treatment, the relevant Secondary Self is usually the Dictator Self.

 Step Two:  De-identification  (similar to [ Assagioli, 2000;, Stone & Winkelman, 1993) - interviewing the Secondary Self :


•    Have the person physically move over from the  Reflecting Self’s chair into the chair or space of the self to be interviewed (usually the Secondary Self).
•    Moderator asks the Secondary Self questions that bring forth who that SS is, its attitudes, scenarios,  its reflection of a patient, etc. Extensive use of Socratic questioning.


Step Three:  Harmonization
Evaluation of conflicts between the Secondary Selves and between certain Secondary Selves and Reflective Self that still persist following the process of de-identification. If detected the conflict is resolves by specially developed mediation techniques.
 
Case Report 1:
R. female, 21y. old, high school graduate, single. History of alternating bulimia and anorectic symptoms since  the age of 12. Individual dynamic psychotherapy for a period of one and a half years, long standing family therapy and hospitalization on a specialized ward for the patients with eating disturbances for a period of 2 months. Despite the therapy, persistence of both bulimic and anorectic symptoms, recently appearance of depressive symptoms with high level of anxiety and sporadic suicidal ideation.
 
On the RGFT diagnostic interview where a patient was questioned  about the most significant persons in her life she reported her father to be in the first place on the significance scale. It was obvious that the internalized image of the father served as a Dictator Self for the patient. During the interview of the internalized image on a “hot chair” her “father” turned out to be a rather dominant person with perfectionist character traits which was very persuasive and criticizing towards his family members including the patient herself.
 
As a result of a deidentification process R. realized already during the first session that many of her character traits originated in father’s influence on her. She understood that the father himself was trapped within his never ending  striving for perfectionism which left him with a high level of anxiety and low self esteem despite his advanced social position.
 
In one of the following sessions R. asked by herself to initiate an interview with her own self representation as she was 7 – just before the birth of her smaller sister. Then, another self representation -  just following the birth of her sister was interviewed. These representations, though in close time proximity were rather distinct. The R. “before” showed herself apprehensive about her future, felt that approaching birth of her sister signifies her mother’s disappointment in R. The R. “after” was a different story altogether. She was full of anger towards her parents that “left” her for the sake of her smaller sister and was out for revenge. “If they don’t want me as their daughter then I don’t need them as my mammy and Dad!”. Another internalized group of her peer friends at the age of 12 when R. showed her first anorectic symptoms demonstrated its eagerness to loose weight in order to line up with the most skinny models. Following seven treatment sessions R. was virtually free of her bulimic symptoms, she has rebuilt her relationships with all the members of her family and entered the University studies. During her 1.5y year follow-up she was still in remission.
 
Case report 2:
 M., female, 22y old, high school graduate. Following the graduation party that lasted until the early morning hours fainted. Shortly after this episode she developed a severe agoraphobia that restricted her to not leaving her house for a period of four and a half years. Several treatment attempts with various antidepressant and anxiolytic medication did not result in any significant symptom relief. Her mother’s internalized image that served as the most dominant Dictator Self happened to demonstrate phobic attitudes in regard to fainting. As a result of the process of deidentification and harmonization, a patient could leave her house after two RGFT sessions and could reintegrate into the working process and restore her social life after 6 sessions. Her remission was still stable on a one year follow-up meeting.
 
 
Conclusions:
The described  novel psychotherapeutic approach Reference Group Focused Therapy  as opposed to other forms of psychotherapy  addresses  the entirety of the patient’s social matrix, including his/her sub-cultural background. 

RGFT addresses not only external person’s reference groups (such as family, working place,  etc.) but his/her internalized groups as well. RGFT belongs to short-term client-centered psycho-therapies, it has already demonstrated its efficacy in different clinical entities such as phobias, OCD, eating disorder, adjustment disorder, somatization, anxiety disorder, panic attacks, and others. One of the crucial components of RGFT is  Trigger Event Analysis – a newly developed tool that enables understanding of person’s vulnerability and allows both the prediction of future conflicts as also searching for the effective ways of avoiding or minimizing them.

The treatment itself focuses on studying the conflicts of both internal (between the internalized groups) and external (between internalized and external groups) origin. One of the main goals of the treatment is to allow a patient to uncover the present (external groups) as well as historical (internalized groups) social influences thus promoting his/her individuation process.  Studies are planned to compare RGFT with other established short-term therapies.
        . female, 22y. old, high school graduate. Following her graduation party that lasted until the morning hours she fainted and shortly after that developed a profound agoraphobia that forced her not to leave her house for about four years.Several treatment attempts with anidepressant and anxiolytic medication did not bring any significant relief in patient’s symptoms. Her mother’s internal image was identified as a predominant Dictator Selfthat that exposed profound phobic attitudes especially fainting that was perceived to be a near death state,As a result of the deidentification process the patient was able to leave her house after two treatment sessions and after six sessions could be reintegrated into the working process and restore her social life  onclusions:


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