Table of Contents

ALSO BY IRVIN D. YALOM

Title Page

Dedication

Preface

Acknowledgements

Chapter 1 – THE THERAPEUTIC FACTORS

INSTILLATION OF HOPE

UNIVERSALITY

IMPARTING INFORMATION

ALTRUISM

THE CORRECTIVE RECAPITULATION OF THE PRIMARY FAMILY GROUP

DEVELOPMENT OF SOCIALIZING TECHNIQUES

IMITATIVE BEHAVIOR

Chapter 2 – INTERPERSONAL LEARNING

THE IMPORTANCE OF INTERPERSONAL RELATIONSHIPS

THE CORRECTIVE EMOTIONAL EXPERIENCE

THE GROUP AS SOCIAL MICROCOSM

THE SOCIAL MICROCOSM: A DYNAMIC INTERACTION

RECOGNITION OF BEHAVIORAL PATTERNS IN THE SOCIAL MICROCOSM

THE SOCIAL MICROCOSM—IS IT REAL?

OVERVIEW

TRANSFERENCE AND INSIGHT

Chapter 3 – GROUP COHESIVENESS

THE IMPORTANCE OF GROUP COHESIVENESS

MECHANISM OF ACTION

SUMMARY

Chapter 4 – THE THERAPEUTIC FACTORS: AN INTEGRATION

COMPARATIVE VALUE OF THE THERAPEUTIC FACTORS: THE CLIENT’S VIEW

COMPARATIVE VALUE OF THE THERAPEUTIC FACTORS: DIFFERENCES BETWEEN CLIENTS’ AND …

THERAPEUTIC FACTORS: MODIFYING FORCES

Chapter 5 – THE THERAPIST: BASIC TASKS

CREATION AND MAINTENANCE OF THE GROUP

CULTURE BUILDING

HOW DOES THE LEADER SHAPE NORMS?

EXAMPLES OF THERAPEUTIC GROUP NORMS

Chapter 6 – THE THERAPIST: WORKING IN THE HERE – AND – NOW

DEFINITION OF PROCESS

PROCESS FOCUS: THE POWER SOURCE OF THE GROUP

THE THERAPIST’S TASKS IN THE HERE-AND-NOW

TECHNIQUES OF HERE-AND-NOW ACTIVATION

TECHNIQUES OF PROCESS ILLUMINATION

HELPING CLIENTS ASSUME A PROCESS ORIENTATION

HELPING CLIENTS ACCEPT PROCESS-ILLUMINATING COMMENTS

PROCESS COMMENTARY: A THEORETICAL OVERVIEW

THE USE OF THE PAST

GROUP – AS – A – WHOLE PROCESS COMMENTARY

Chapter 7 – THE THERAPIST: TRANSFERENCE AND TRANSPARENCY

TRANSFERENCE IN THE THERAPY GROUP

THE PSYCHOTHERAPIST AND TRANSPARENCY

Chapter 8 – THE SELECTION OF CLIENTS

CRITERIA FOR EXCLUSION

CRITERIA FOR INCLUSION

AN OVERVIEW OF THE SELECTION PROCEDURE

SUMMARY

Chapter 9 – THE COMPOSITION OF THERAPY GROUPS

THE PREDICTION OF GROUP BEHAVIOR

PRINCIPLES OF GROUP COMPOSITION

OVERVIEW

A FINAL CAVEAT

Chapter 10 – CREATION OF THE GROUP: PLACE, TIME, SIZE, PREPARATION

PRELIMINARY CONSIDERATIONS

DURATION AND FREQUENCY OF MEETINGS

BRIEF GROUP THERAPY

PREPARATION FOR GROUP THERAPY

Chapter 11 – IN THE BEGINNING

FORMATIVE STAGES OF THE GROUP

THE IMPACT OF CLIENTS ON GROUP DEVELOPMENT

MEMBERSHIP PROBLEMS

Chapter 12 – THE ADVANCED GROUP

SUBGROUPING

CONFLICT IN THE THERAPY GROUP

SELF-DISCLOSURE

TERMINATION

Chapter 13 – PROBLEM GROUP MEMBERS

THE MONOPOLIST

THE SILENT CLIENT

THE BORING CLIENT

THE HELP-REJECTING COMPLAINER

THE PSYCHOTIC OR BIPOLAR CLIENT

THE CHARACTEROLOGICALLY DIFFICULT CLIENT

Chapter 14 – THE THERAPIST: SPECIALIZED FORMATS AND PROCEDURAL AIDS

CONCURRENT INDIVIDUAL AND GROUP THERAPY

COMBINING GROUP THERAPY AND TWELVE-STEP GROUPS

CO-THERAPISTS

THE LEADERLESS MEETING

DREAMS

AUDIOVISUAL TECHNOLOGY

WRITTEN SUMMARIES

GROUP THERAPY RECORD KEEPING

STRUCTURED EXERCISES

Chapter 15 – SPECIALIZED THERAPY GROUPS

MODIFICATION OF TRADITIONAL GROUP THERAPY FOR SPECIALIZED CLINICAL SITUATIONS: …

THE ACUTE INPATIENT THERAPY GROUP

GROUPS FOR THE MEDICALLY ILL

ADAPTATION OF CBT AND IPT TO GROUP THERAPY

SELF-HELP GROUPS AND INTERNET SUPPORT GROUPS

Chapter 16 – GROUP THERAPY: ANCESTORS AND COUSINS

WHAT IS AN ENCOUNTER GROUP?

ANTECEDENTS AND EVOLUTION OF THE ENCOUNTER GROUP

GROUP THERAPY FOR NORMALS

THE EFFECTIVENESS OF THE ENCOUNTER GROUP

THE RELATIONSHIP BETWEEN THE ENCOUNTER GROUP AND THE THERAPY GROUP

Chapter 17 – TRAINING THE GROUP THERAPIST

OBSERVATION OF EXPERIENCED CLINICIANS

SUPERVISION

A GROUP EXPERIENCE FOR TRAINEES

PERSONAL PSYCHOTHERAPY

SUMMARY

BEYOND TECHNIQUE

Appendix – Information and Guidelines for Participation in Group Therapy

Notes

Index

Copyright Page

ALSO BY IRVIN D. YALOM Existential Psychotherapy

Every Day Gets a Little Closer: A Twice-Told Therapy (with Ginny Elkin)

Encounter Groups: First Facts (with Morton A. Lieberman and Matthew B. Miles)

Inpatient Group Psychotherapy Concise Guide to Group Psychotherapy

(with Sophia Vinogradov) Love’s Executioner When Nietzsche Wept Lying on the Couch

Momma and the Meaning of Life The Gift of Therapy

The Schopenhauer Cure

ALSO BY MOLYN LESZCZ

Treating the Elderly with Psychotherapy: The Scope for Change in Later Life

(with Joel Sadavoy)

To the memory of my mother and father, RUTH YALOM and BENJAMIN YALOM

To the memory of my mother and father, CLARA LESZCZ and SAUL LESZCZ

Preface to the Fifth Edition For this fifth edition of The Theory and Practice of Psychotherapy I have had the good fortune of having Molyn Leszcz as my collaborator. Dr. Leszcz, whom I first met in 1980 when he spent a yearlong fellowship in group therapy with me at Stanford University, has been a major contributor to research and clinical innovation in group therapy. For the past twelve years, he has directed one of the largest group therapy training programs in the world in the Department of Psychiatry at the University of Toronto, where he is an associate professor. His broad knowledge of contemporary group practice and his exhaustive review of the research and clinical literature were invaluable to the preparation of this volume. We worked diligently, like co-therapists, to make this edition a seamless integration of new and old material. Although for stylistic integrity we opted to retain the first-person singular in this text, behind the “I” there is always a collaborative “we.”

Our task in this new edition was to incorporate the many new changes in the field and to jettison outmoded ideas and methods. But we had a dilemma: What if some of the changes in the field do not represent advances but, instead, retrogression? What if marketplace considerations demanding quicker, cheaper, more efficient methods act against the best interests of the client? And what if “efficiency” is but a euphemism for shedding clients from the fiscal rolls as quickly as possible? And what if these diverse market factors force therapists to offer less than they are capable of offering their clients?

If these suppositions are true, then the requirements of this revision become far more complex because we have a dual task: not only to present current methods and prepare student therapists for the contemporary workplace, but also to preserve the accumulated wisdom and techniques of our field even if some young therapists will not have immediate opportunities to apply them.

Since group therapy was first introduced in the 1940s, it has undergone a series of adaptations to meet the changing face of clinical practice. As new clinical syndromes, settings, and theoretical approaches have emerged, so have corresponding variants of group therapy. The multiplicity of forms is so evident today that it makes more sense to speak of “group therapies” than of “group therapy.” Groups for panic disorder, groups for acute and chronic depression, groups to prevent depression relapse, groups for eating disorders, medical support groups for patients with cancer, HIV/AIDS, rheumatoid arthritis, multiple sclerosis, irritable bowel syndrome, obesity, myocardial infarction, paraplegia, diabetic blindness, renal failure, bone marrow transplant, Parkinson’s, groups for healthy men and women who carry genetic mutations that predispose them to develop cancer, groups for victims of sexual abuse, for the confused elderly and for their caregivers, for clients with obsessive-compulsive disorder, first-episode schizophrenia, for chronic schizophrenia, for adult children of alcoholics, for parents of sexually abused children, for male batterers, for self-mutilators, for the divorced, for the bereaved, for disturbed families, for married couples—all of these, and many more, are forms of group therapy.

The clinical settings of group therapy are also diverse: a rapid turnover group for

chronically or acutely psychotic patients on a stark hospital ward is group therapy, and so are groups for imprisoned sex offenders, groups for residents of a shelter for battered women, and open-ended groups of relatively well functioning individuals with neurotic or personality disorders meeting in the well-appointed private office of a psychotherapist.

And the technical approaches are bewilderingly different: cognitive-behavioral, psychoeducational, interpersonal, gestalt, supportive-expressive, psychoanalytic, dynamic- interactional, psychodrama—all of these, and many more, are used in group therapy.

This family gathering of group therapies is swollen even more by the presence of distant cousins to therapy groups entering the room: experiential classroom training groups (or process groups) and the numerous self-help (or mutual support) groups like Alcoholics Anonymous and other twelve-step recovery groups, Adult Survivors of Incest, Sex Addicts Anonymous, Parents of Murdered Children, Overeaters Anonymous, and Recovery, Inc. Although these groups are not formal therapy groups, they are very often therapeutic and straddle the blurred borders between personal growth, support, education, and therapy (see chapter 16 for a detailed discussion of this topic). And we must also consider the youngest, most rambunctious, and most unpredictable of the cousins: the Internet support groups, offered in a rainbow of flavors.

How, then, to write a single book that addresses all these group therapies? The strategy I chose thirty-five years ago when I wrote the first edition of this book seems sound to me still. My first step was to separate “front” from “core” in each of the group therapies. The front consists of the trappings, the form, the techniques, the specialized language, and the aura surrounding each of the ideological schools; the core consists of those aspects of the experience that are intrinsic to the therapeutic process—that is, the bare-boned mechanisms of change.

If you disregard the “front” and consider only the actual mechanisms of effecting change in the client, you will find that the change mechanisms are limited in number and are remarkably similar across groups. Therapy groups with similar goals that appear wildly different in external form may rely on identical mechanisms of change.

In the first two editions of this book, caught up in the positivistic zeitgeist surrounding the developing psychotherapies, I referred to these mechanisms of change as “curative factors.” Educated and humbled by the passing years, I know now that the harvest of psychotherapy is not cure—surely, in our field, that is an illusion—but instead change or growth. Hence, yielding to the dictates of reality, I now refer to the mechanisms of change as “therapeutic factors” rather than “curative factors.”

The therapeutic factors constitute the central organizing principle of this book. I begin with a detailed discussion of eleven therapeutic factors and then describe a psychotherapeutic approach that is based on them.

But which types of groups to discuss? The array of group therapies is now so vast that it is impossible for a text to address each type of group separately. How then to proceed? I have chosen in this book to center my discussion around a prototypic type of group therapy and then to offer a set of principles that will enable the therapist to modify this

fundamental group model to fit any specialized clinical situation.

The prototypical model is the intensive, heterogeneously composed outpatient psychotherapy group, meeting for at least several months, with the ambitious goals of both symptomatic relief and personality change. Why focus on this particular form of group therapy when the contemporary therapy scene, driven by economic factors, is dominated by another type of group—a homogeneous, symptom-oriented group that meets for briefer periods and has more limited goals?

The answer is that long-term group therapy has been around for many decades and has accumulated a vast body of knowledge from both empirical research and thoughtful clinical observation. Earlier I alluded to contemporary therapists not often having the clinical opportunities to do their best work; I believe that the prototypical group we describe in this book is the setting in which therapists can offer maximum benefit to their clients. It is an intensive, ambitious form of therapy that demands much from both client and therapist. The therapeutic strategies and techniques required to lead such a group are sophisticated and complex. However, once students master them and understand how to modify them to fit specialized therapy situations, they will be in a position to fashion a group therapy that will be effective for any clinical population in any setting. Trainees should aspire to be creative and compassionate therapists with conceptual depth, not laborers with little vision and less morale. Managed care emphatically views group therapy as the treatment modality of the future. Group therapists must be as prepared as possible for this opportunity.

Because most readers of this book are clinicians, the text is intended to have immediate clinical relevance. I also believe, however, that it is imperative for clinicians to remain conversant with the world of research. Even if therapists do not personally engage in research, they must know how to evaluate the research of others. Accordingly, the text relies heavily on relevant clinical, social, and psychological research.

While searching through library stacks during the writing of early editions of this book, I often found myself browsing in antiquated psychiatric texts. How unsettling it is to realize that the devotees of such therapy endeavors as hydrotherapy, rest cures, lobotomy, and insulin coma were obviously clinicians of high intelligence, dedication, and integrity. The same may be said of earlier generations of therapists who advocated venesection, starvation, purgation, and trephination. Their texts are as well written, their optimism as unbridled, and their reported results as impressive as those of contemporary practitioners.

Question: why have other health-care fields left treatment of psychological disturbance so far behind? Answer: because they have applied the principles of the scientific method. Without a rigorous research base, the psychotherapists of today who are enthusiastic about current treatments are tragically similar to the hydrotherapists and lobotomists of yesteryear. As long as we do not test basic principles and treatment outcomes with scientific rigor, our field remains at the mercy of passing fads and fashions. Therefore, whenever possible, the approach presented in this text is based on rigorous, relevant research, and attention is called to areas in which further research seems especially necessary and feasible. Some areas (for example, preparation for group therapy and the

reasons for group dropouts) have been widely and competently studied, while other areas (for example, “working through” or countertransference) have only recently been touched by research. Naturally, this distribution of research emphasis is reflected in the text: some chapters may appear, to clinicians, to stress research too heavily, while other chapters may appear, to research-minded colleagues, to lack rigor.

Let us not expect more of psychotherapy research than it can deliver. Will the findings of psychotherapy research affect a rapid major change in therapy practice? Probably not. Why? “Resistance” is one reason. Complex systems of therapy with adherents who have spent many years in training and apprenticeship and cling stubbornly to tradition will change slowly and only in the face of very substantial evidence. Furthermore, front-line therapists faced with suffering clients obviously cannot wait for science. Also, keep in mind the economics of research. The marketplace controls the focus of research. When managed-care economics dictated a massive swing to brief, symptom-oriented therapy, reports from a multitude of well-funded research projects on brief therapy began to appear in the literature. At the same time, the bottom dropped out of funding sources for research on longer-term therapy, despite a strong clinical consensus about the importance of such research. In time we expect that this trend will be reversed and that more investigation of the effectiveness of psychotherapy in the real world of practice will be undertaken to supplement the knowledge accruing from randomized controlled trials of brief therapy. Another consideration is that, unlike in the physical sciences, many aspects of psychotherapy inherently defy quantification. Psychotherapy is both art and science; research findings may ultimately shape the broad contours of practice, but the human encounter at the center of therapy will always be a deeply subjective, nonquantifiable experience.

One of the most important underlying assumptions in this text is that interpersonal interaction within the here-and-now is crucial to effective group therapy. The truly potent therapy group first provides an arena in which clients can interact freely with others, then helps them identify and understand what goes wrong in their interactions, and ultimately enables them to change those maladaptive patterns. We believe that groups based solely on other assumptions, such as psychoeducational or cognitive-behavioral principles, fail to reap the full therapeutic harvest. Each of these forms of group therapy can be made even more effective by incorporating an awareness of interpersonal process.

This point needs emphasis: It has great relevance for the future of clinical practice. The advent of managed care will ultimately result in increased use of therapy groups. But, in their quest for efficiency, brevity, and accountability, managed-care decision makers may make the mistake of decreeing that some distinct orientations (brief, cognitive-behavioral, symptom-focused) are more desirable because their approach encompasses a series of steps consistent with other efficient medical approaches: the setting of explicit, limited goals; the measuring of goal attainment at regular, frequent intervals; a highly specific treatment plan; and a replicable, uniform, manual-driven, highly structured therapy with a precise protocol for each session. But do not mistake the appearance of efficiency for true effectiveness.

In this text we discuss, in depth, the extent and nature of the interactional focus and its potency in bringing about significant character and interpersonal change. The interactional focus is the engine of group therapy, and therapists who are able to harness it are much better equipped to do all forms of group therapy, even if the group model does not emphasize or acknowledge the centrality of interaction.

Initially I was not eager to undertake the considerable task of revising this text. The theoretical foundations and technical approach to group therapy described in the fourth edition remain sound and useful. But a book in an evolving field is bound to age sooner than later, and the last edition was losing some of its currency. Not only did it contain dated or anachronistic allusions, but also the field has changed. Managed care has settled in by now, DSM-IV has undergone a text revision (DSM-IV-TR), and a decade of clinical and research literature needed to be reviewed and assimilated into the text. Furthermore, new types of groups have sprung up and others have faded away. Cognitive-behavioral, psychoeducational, and problem-specific brief therapy groups are becoming more common, so in this revision we have made a special effort throughout to address the particular issues germane to these groups.

The first four chapters of this text discuss eleven therapeutic factors. Chapter 1 covers instillation of hope, universality, imparting information, altruism, the corrective recapitulation of the primary family group, the development of socializing techniques, and imitative behavior. Chapters 2 and 3 present the more complex and powerful factors of interpersonal learning and cohesiveness. Recent advances in our understanding of interpersonal theory and the therapeutic alliance that can strengthen therapist effectiveness have influenced our approach to these two chapters.

Chapter 4 discusses catharsis and existential factors and then attempts a synthesis by addressing the comparative importance and the interdependence of all eleven therapeutic factors.

The next two chapters address the work of the therapist. Chapter 5 discusses the tasks of the group therapist—especially those germane to shaping a therapeutic group culture and harnessing the group interaction for therapeutic benefit. Chapter 6 describes how the therapist must first activate the here-and-now (that is, plunge the group into its own experience) and then illuminate the meaning of the here-and-now experience. In this edition we deemphasize certain models that rely on the elucidation of group-as-a-whole dynamics (for example, the Tavistock approach)—models that have since proven ineffective in the therapy process. (Some omitted material that may still interest some readers will remain available at www.yalom.com.)

While chapters 5 and 6 address what the therapist must do, chapter 7 addresses how the therapist must be. It explicates the therapist’s role and the therapist’s use of self by focusing on two fundamental issues: transference and transparency. In previous editions, I felt compelled to encourage therapist restraint: Many therapists were still so influenced by the encounter group movement that they, too frequently and too extensively, “let it all hang out.” Times have changed; more conservative forces have taken hold, and now we feel compelled to discourage therapists from practicing too defensively. Manyhttp://www.yalom.com

contemporary therapists, threatened by the encroachment of the legal profession into the field (a result of the irresponsibility and misconduct of some therapists, coupled with a reckless and greedy malpractice industry), have grown too cautious and impersonal. Hence we give much attention to the use of the therapist’s self in psychotherapy.

Chapters 8 through 14 present a chronological view of the therapy group and emphasize group phenomena and techniques that are relevant to each stage. Chapters 8 and 9, on client selection and group composition, include new research data on group therapy attendance, dropouts, and outcomes. Chapter 10, which describes the practical realities of beginning a group, includes a lengthy new section on brief group therapy, presents much new research on the preparation of the client for group therapy. The appendix contains a document to distribute to new members to help prepare them for their work in the therapy group.

Chapter 11 addresses the early stages of the therapy group and includes new material on dealing with the therapy dropout. Chapter 12 deals with phenomena encountered in the mature phase of the group therapy work: subgrouping, conflict, self-disclosure, and termination.

Chapter 13, on problem members in group therapy, adds new material to reflect advances in interpersonal theory. It discusses the contributions of intersubjectivity, attachment theory, and self psychology. Chapter 14 discusses specialized techniques of the therapist, including concurrent individual and group therapy (both combined and conjoint), co-therapy, leaderless meetings, dreams, videotaping, and structured exercises, the use of the written summary in group therapy, and the integration of group therapy and twelve-step programs.

Chapter 15, on specialized therapy groups, addresses the many new groups that have emerged to deal with specific clinical syndromes or clinical situations. It presents the critically important principles used to modify traditional group therapy technique in order to design a group to meet the needs of other specialized clinical situations and populations, and describes the adaptation of cognitive-behavioral and interpersonal therapy to groups. These principles are illustrated by in-depth discussions of various groups, such as the acute psychiatric inpatient group and groups for the medically ill (with a detailed illustration of a group for patients with cancer). Chapter 15 also discusses self-help groups and the youngest member of the group therapy family—the Internet support group.

Chapter 16, on the encounter group, presented the single greatest challenge for this revision. Because the encounter group qua encounter group has faded from contemporary culture, we considered omitting the chapter entirely. However, several factors argue against an early burial: the important role played by the encounter movement groups in developing research technology and the use of encounter groups (also known as process groups, T-groups (for “training”), or experiential training groups) in group psychotherapy education. Our compromise was to shorten the chapter considerably and to make the entire fourth edition chapter available at www.yalom.com for readers who are interested in the history and evolution of the encounter movement.

Chapter 17, on the training of group therapists, includes new approaches to thehttp://www.yalom.com

supervision process and on the use of process groups in the educational curriculum.

During the four years of preparing this revision I was also engaged in writing a novel, The Schopenhauer Cure, which may serve as a companion volume to this text: It is set in a therapy group and illustrates many of the principles of group process and therapist technique offered in this text. Hence, at several points in this fifth edition, I refer the reader to particular pages in The Schopenhauer Cure that offer fictionalized portrayals of therapist techniques.

Excessively overweight volumes tend to gravitate to the “reference book” shelves. To avoid that fate we have resisted lengthening this text. The addition of much new material has mandated the painful task of cutting older sections and citations. (I left my writing desk daily with fingers stained by the blood of many condemned passages.) To increase readability, we consigned almost all details and critiques of research method to footnotes or to notes at the end of the book. The review of the last ten years of group therapy literature has been exhaustive.

Most chapters contain 50–100 new references. In several locations throughout the book, we have placed a dagger (†) to indicate that corroborative observations or data exist for suggested current readings for students interested in that particular area. This list of references and suggested readings has been placed on my website, www.yalom.com.http://www.yalom.com

Acknowledgments (Irvin Yalom)

I am grateful to Stanford University for providing the academic freedom, library facilities, and administrative staff necessary to accomplish this work. To a masterful mentor, Jerome Frank (who died just before the publication of this edition), my thanks for having introduced me to group therapy and for having offered a model of integrity, curiosity, and dedication. Several have assisted in this revision: Stephanie Brown, Ph.D. (on twelve-step groups), Morton Lieberman, Ph.D. (on Internet groups), Ruthellen Josselson, Ph.D. (on group-as-a-whole interventions), David Spiegel (on medical groups), and my son Ben Yalom, who edited several chapters.

(Molyn Leszcz)

I am grateful to the University of Toronto Department of Psychiatry for its support in this project. Toronto colleagues who have made comments on drafts of this edition and facilitated its completion include Joel Sadavoy, M.D., Don Wasylenki, M.D., Danny Silver, M.D., Paula Ravitz, M.D., Zindel Segal, Ph.D., Paul Westlind, M.D., Ellen Margolese, M.D., Jan Malat, M.D., and Jon Hunter, M.D. Liz Konigshaus handled the painstaking task of word-processing, with enormous efficiency and unyielding good nature. Benjamin, Talia, and Noah Leszcz, my children, and Bonny Leszcz, my wife, contributed insight and encouragement throughout.

Chapter 1

THE THERAPEUTIC FACTORS Does group therapy help clients? Indeed it does. A persuasive body of outcome research has demonstrated unequivocally that group therapy is a highly effective form of psychotherapy and that it is at least equal to individual psychotherapy in its power to provide meaningful benefit.1

How does group therapy help clients? A naive question, perhaps. But if we can answer it with some measure of precision and certainty, we will have at our disposal a central organizing principle with which to approach the most vexing and controversial problems of psychotherapy. Once identified, the crucial aspects of the process of change will constitute a rational basis for the therapist’s selection of tactics and strategies to shape the group experience to maximize its potency with different clients and in different settings.

I suggest that therapeutic change is an enormously complex process that occurs through an intricate interplay of human experiences, which I will refer to as “therapeutic factors.” There is considerable advantage in approaching the complex through the simple, the total phenomenon through its basic component processes. Accordingly, I begin by describing and discussing these elemental factors.

From my perspective, natural lines of cleavage divide the therapeutic experience into eleven primary factors:

1. Instillation of hope

2. Universality

3. Imparting information

4. Altruism

5. The corrective recapitulation of the primary family group

6. Development of socializing techniques

7. Imitative behavior

8. Interpersonal learning

9. Group cohesiveness

10. Catharsis

11. Existential factors

In the rest of this chapter, I discuss the first seven factors. I consider interpersonal learning and group cohesiveness so important and complex that I have treated them separately, in the next two chapters. Existential factors are discussed in chapter 4, where they are best understood in the context of other material presented there. Catharsis is intricately interwoven with other therapeutic factors and will also be discussed in chapter

4.

The distinctions among these factors are arbitrary. Although I discuss them singly, they are interdependent and neither occur nor function separately. Moreover, these factors may represent different parts of the change process: some factors (for example, self- understanding) act at the level of cognition; some (for example, development of socializing techniques) act at the level of behavioral change; some (for example, catharsis) act at the level of emotion; and some (for example, cohesiveness) may be more accurately described as preconditions for change.† Although the same therapeutic factors operate in every type of therapy group, their interplay and differential importance can vary widely from group to group. Furthermore, because of individual differences, participants in the same group benefit from widely different clusters of therapeutic factors.†

Keeping in mind that the therapeutic factors are arbitrary constructs, we can view them as providing a cognitive map for the student-reader. This grouping of the therapeutic factors is not set in concrete; other clinicians and researchers have arrived at a different, and also arbitrary, clusters of factors.2 No explanatory system can encompass all of therapy. At its core, the therapy process is infinitely complex, and there is no end to the number of pathways through the experience. (I will discuss all of these issues more fully in chapter 4.)

The inventory of therapeutic factors I propose issues from my clinical experience, from the experience of other therapists, from the views of the successfully treated group patient, and from relevant systematic research. None of these sources is beyond doubt, however; neither group members nor group leaders are entirely objective, and our research methodology is often crude and inapplicable.

From the group therapists we obtain a variegated and internally inconsistent inventory of therapeutic factors (see chapter 4). Therapists, by no means disinterested or unbiased observers, have invested considerable time and energy in mastering a certain therapeutic approach. Their answers will be determined largely by their particular school of conviction. Even among therapists who share the same ideology and speak the same language, there may be no consensus about the reasons clients improve. In research on encounter groups, my colleagues and I learned that many successful group leaders attributed their success to factors that were irrelevant to the therapy process: for example, the hot-seat technique, or nonverbal exercises, or the direct impact of a therapist’s own person (see chapter 16).3 But that does not surprise us. The history of psychotherapy abounds in healers who were effective, but not for the reasons they supposed. At other times we therapists throw up our hands in bewilderment. Who has not had a client who made vast improvement for entirely obscure reasons?

Group members at the end of a course of group therapy can supply data about the therapeutic factors they considered most and least helpful. Yet we know that such evaluations will be incomplete and their accuracy limited. Will the group members not, perhaps, focus primarily on superficial factors and neglect some profound healing forces that may be beyond their awareness? Will their responses not be influenced by a variety of factors difficult to control? It is entirely possible, for example, that their views may be

distorted by the nature of their relationship to the therapist or to the group. (One team of researchers demonstrated that when patients were interviewed four years after the conclusion of therapy, they were far more apt to comment on unhelpful or harmful aspects of their group experience than when interviewed immediately at its conclusion.)4 Research has also shown, for example, that the therapeutic factors valued by group members may differ greatly from those cited by their therapists or by group observers,5 an observation also made in individual psychotherapy. Furthermore, many confounding factors influence the client’s evaluation of the therapeutic factors: for example, the length of time in treatment and the level of a client’s functioning,6 the type of group (that is, whether outpatient, inpatient, day hospital, brief therapy),7 the age and the diagnosis of a client,8

and the ideology of the group leader.9 Another factor that complicates the search for common therapeutic factors is the extent to which different group members perceive and experience the same event in different ways.† Any given experience may be important or helpful to some and inconsequential or even harmful to others.

Despite these limitations, clients’ reports are a rich and relatively untapped source of information. After all, it is their experience, theirs alone, and the farther we move from the clients’ experience, the more inferential are our conclusions. To be sure, there are aspects of the process of change that operate outside a client’s awareness, but it does not follow that we should disregard what clients do say.

There is an art to obtaining clients’ reports. Paper-and-pencil or sorting questionnaires provide easy data but often miss the nuances and the richness of the clients’ experience. The more the questioner can enter into the experiential world of the client, the more lucid and meaningful the report of the therapy experience becomes. To the degree that the therapist is able to suppress personal bias and avoid influencing the client’s responses, he or she becomes the ideal questioner: the therapist is trusted and understands more than anyone else the inner world of the client.

In addition to therapists’ views and clients’ reports, there is a third important method of evaluating the therapeutic factors: the systematic research approach. The most common research strategy by far is to correlate in-therapy variables with outcome in therapy. By discovering which variables are significantly related to successful outcomes, one can establish a reasonable base from which to begin to delineate the therapeutic factors. However, there are many inherent problems in this approach: the measurement of outcome is itself a methodological morass, and the selection and measurement of the in-therapy variables are equally problematic.a10

I have drawn from all these methods to derive the therapeutic factors discussed in this book. Still, I do not consider these conclusions definitive; rather, I offer them as provisional guidelines that may be tested and deepened by other clinical researchers. For my part, I am satisfied that they derive from the best available evidence at this time and that they constitute the basis of an effective approach to therapy.

INSTILLATION OF HOPE

The instillation and maintenance of hope is crucial in any psychotherapy. Not only is hope required to keep the client in therapy so that other therapeutic factors may take effect, but faith in a treatment mode can in itself be therapeutically effective. Several studies have demonstrated that a high expectation of help before the start of therapy is significantly correlated with a positive therapy outcome.11 Consider also the massive data documenting the efficacy of faith healing and placebo treatment—therapies mediated entirely through hope and conviction. A positive outcome in psychotherapy is more likely when the client and the therapist have similar expectations of the treatment.12 The power of expectations extends beyond imagination alone. Recent brain imaging studies demonstrate that the placebo is not inactive but can have a direct physiological effect on the brain.13

Group therapists can capitalize on this factor by doing whatever we can to increase clients’ belief and confidence in the efficacy of the group mode. This task begins before the group starts, in the pregroup orientation, in which the therapist reinforces positive expectations, corrects negative preconceptions, and presents a lucid and powerful explanation of the group’s healing properties. (See chapter 10 for a full discussion of the pregroup preparation procedure.)

Group therapy not only draws from the general ameliorative effects of positive expectations but also benefits from a source of hope that is unique to the group format. Therapy groups invariably contain individuals who are at different points along a coping- collapse continuum. Each member thus has considerable contact with others—often individuals with similar problems—who have improved as a result of therapy. I have often heard clients remark at the end of their group therapy how important it was for them to have observed the improvement of others. Remarkably, hope can be a powerful force even in groups of individuals combating advanced cancer who lose cherished group members to the disease. Hope is flexible—it redefines itself to fit the immediate parameters, becoming hope for comfort, for dignity, for connection with others, or for minimum physical discomfort.14

Group therapists should by no means be above exploiting this factor by periodically calling attention to the improvement that members have made. If I happen to receive notes from recently terminated members informing me of their continued improvement, I make a point of sharing this with the current group. Senior group members often assume this function by offering spontaneous testimonials to new, skeptical members.

Research has shown that it is also vitally important that therapists believe in themselves and in the efficacy of their group.15 I sincerely believe that I am able to help every motivated client who is willing to work in the group for at least six months. In my initial meetings with clients individually, I share this conviction with them and attempt to imbue them with my optimism.

Many of the self-help groups—for example, Compassionate Friends (for bereaved

parents), Men Overcoming Violence (men who batter), Survivors of Incest, and Mended Heart (heart surgery patients)—place heavy emphasis on the instillation of hope.16 A major part of Recovery, Inc. (for current and former psychiatric patients) and Alcoholics Anonymous meetings is dedicated to testimonials. At each meeting, members of Recovery, Inc. give accounts of potentially stressful incidents in which they avoided tension by the application of Recovery, Inc. methods, and successful Alcoholics Anonymous members tell their stories of downfall and then rescue by AA. One of the great strengths of Alcoholics Anonymous is the fact that the leaders are all alcoholics— living inspirations to the others.

Substance abuse treatment programs commonly mobilize hope in participants by using recovered drug addicts as group leaders. Members are inspired and expectations raised by contact with those who have trod the same path and found the way back. A similar approach is used for individuals with chronic medical illnesses such as arthritis and heart disease. These self-management groups use trained peers to encourage members to cope actively with their medical conditions.17 The inspiration provided to participants by their peers results in substantial improvements in medical outcomes, reduces health care costs, promotes the individual’s sense of self-efficacy, and often makes group interventions superior to individual therapies.18

UNIVERSALITY

Many individuals enter therapy with the disquieting thought that they are unique in their wretchedness, that they alone have certain frightening or unacceptable problems, thoughts, impulses, and fantasies. Of course, there is a core of truth to this notion, since most clients have had an unusual constellation of severe life stresses and are periodically flooded by frightening material that has leaked from their unconscious.

To some extent this is true for all of us, but many clients, because of their extreme social isolation, have a heightened sense of uniqueness. Their interpersonal difficulties preclude the possibility of deep intimacy. In everyday life they neither learn about others’ analogous feelings and experiences nor avail themselves of the opportunity to confide in, and ultimately to be validated and accepted by, others.

In the therapy group, especially in the early stages, the disconfirmation of a client’s feelings of uniqueness is a powerful source of relief. After hearing other members disclose concerns similar to their own, clients report feeling more in touch with the world and describe the process as a “welcome to the human race” experience. Simply put, the phenomenon finds expression in the cliché “We’re all in the same boat”—or perhaps more cynically, “Misery loves company.”

There is no human deed or thought that lies fully outside the experience of other people. I have heard group members reveal such acts as incest, torture, burglary, embezzlement, murder, attempted suicide, and fantasies of an even more desperate nature. Invariably, I

have observed other group members reach out and embrace these very acts as within the realm of their own possibilities, often following through the door of disclosure opened by one group member’s trust or courage. Long ago Freud noted that the staunchest taboos (against incest and patricide) were constructed precisely because these very impulses are part of the human being’s deepest nature.

Nor is this form of aid limited to group therapy. Universality plays a role in individual therapy also, although in that format there is less opportunity for consensual validation, as therapists choose to restrict their degree of personal transparency.

During my own 600-hour analysis I had a striking personal encounter with the therapeutic factor of universality. It happened when I was in the midst of describing my extremely ambivalent feelings toward my mother. I was very much troubled by the fact that, despite my strong positive sentiments, I was also beset with death wishes for her, as I stood to inherit part of her estate. My analyst responded simply, “That seems to be the way we’re built.” That artless statement not only offered me considerable relief but enabled me to explore my ambivalence in great depth.

Despite the complexity of human problems, certain common denominators between individuals are clearly evident, and the members of a therapy group soon perceive their similarities to one another. An example is illustrative: For many years I asked members of T-groups (these are nonclients—primarily medical students, psychiatric residents, nurses, psychiatric technicians, and Peace Corps volunteers; see chapter 16) to engage in a “top- secret” task in which they were asked to write, anonymously, on a slip of paper the one thing they would be most disinclined to share with the group. The secrets prove to be startlingly similar, with a couple of major themes predominating. The most common secret is a deep conviction of basic inadequacy—a feeling that one is basically incompetent, that one bluffs one’s way through life. Next in frequency is a deep sense of interpersonal alienation—that, despite appearances, one really does not, or cannot, care for or love another person. The third most frequent category is some variety of sexual secret. These chief concerns of nonclients are qualitatively the same in individuals seeking professional help. Almost invariably, our clients experience deep concern about their sense of worth and their ability to relate to others.b

Some specialized groups composed of individuals for whom secrecy has been an especially important and isolating factor place a particularly great emphasis on universality. For example, short-term structured groups for bulimic clients build into their protocol a strong requirement for self-disclosure, especially disclosure about attitudes toward body image and detailed accounts of each member’s eating rituals and purging practices. With rare exceptions, patients express great relief at discovering that they are not alone, that others share the same dilemmas and life experiences.19

Members of sexual abuse groups, too, profit enormously from the experience of universality.20 An integral part of these groups is the intimate sharing, often for the first time in each member’s life, of the details of the abuse and the ensuing internal devastation they suffered. Members in such groups can encounter others who have suffered similar violations as children, who were not responsible for what happened to them, and who have

also suffered deep feelings of shame, guilt, rage, and uncleanness. A feeling of universality is often a fundamental step in the therapy of clients burdened with shame, stigma, and self-blame, for example, clients with HIV/AIDS or those dealing with the aftermath of a suicide.21

Members of homogeneous groups can speak to one another with a powerful authenticity that comes from their firsthand experience in ways that therapists may not be able to do. For instance, I once supervised a thirty-five-year-old therapist who was leading a group of depressed men in their seventies and eighties. At one point a seventy-seven-year-old man who had recently lost his wife expressed suicidal thoughts. The therapist hesitated, fearing that anything he might say would come across as naive. Then a ninety-one-year-old group member spoke up and described how he had lost his wife of sixty years, had plunged into a suicidal despair, and had ultimately recovered and returned to life. That statement resonated deeply and was not easily dismissed.

In multicultural groups, therapists may need to pay particular attention to the clinical factor of universality. Cultural minorities in a predominantly Caucasian group may feel excluded because of different cultural attitudes toward disclosure, interaction, and affective expression. Therapists must help the group move past a focus on concrete cultural differences to transcultural—that is, universal—responses to human situations and tragedies.22 At the same time, therapists must be keenly aware of the cultural factors at play. Mental health professionals are often sorely lacking in knowledge of the cultural facts of life required to work effectively with culturally diverse members. It is imperative that therapists learn as much as possible about their clients’ cultures as well as their attachment to or alienation from their culture.23

Universality, like the other therapeutic factors, does not have sharp borders; it merges with other therapeutic factors. As clients perceive their similarity to others and share their deepest concerns, they benefit further from the accompanying catharsis and from their ultimate acceptance by other members (see chapter 3 on group cohesiveness).

IMPARTING INFORMATION

Under the general rubric of imparting information, I include didactic instruction about mental health, mental illness, and general psychodynamics given by the therapists as well as advice, suggestions, or direct guidance from either the therapist or other group members.

Didactic Instruction

Most participants, at the conclusion of successful interactional group therapy, have learned a great deal about psychic functioning, the meaning of symptoms, interpersonal and group

dynamics, and the process of psychotherapy. Generally, the educational process is implicit; most group therapists do not offer explicit didactic instruction in interactional group therapy. Over the past decade, however, many group therapy approaches have made formal instruction, or psychoeducation, an important part of the program.

One of the more powerful historical precedents for psychoeducation can be found in the work of Maxwell Jones, who in his work with large groups in the 1940s lectured to his patients three hours a week about the nervous system’s structure, function, and relevance to psychiatric symptoms and disability.24

Marsh, writing in the 1930s, also believed in the importance of psychoeducation and organized classes for his patients, complete with lectures, homework, and grades.25

Recovery, Inc., the nation’s oldest and largest self-help program for current and former psychiatric patients, is basically organized along didactic lines.26 Founded in 1937 by Abraham Low, this organization has over 700 operating groups today.27 Membership is voluntary, and the leaders spring from the membership. Although there is no formal professional guidance, the conduct of the meetings has been highly structured by Dr. Low; parts of his textbook, Mental Health Through Will Training,28 are read aloud and discussed at every meeting. Psychological illness is explained on the basis of a few simple principles, which the members memorize—for example, the value of “spotting” troublesome and self-undermining behaviors; that neurotic symptoms are distressing but not dangerous; that tension intensifies and sustains the symptom and should be avoided; that the use of one’s free will is the solution to the nervous patient’s dilemmas.

Many other self-help groups strongly emphasize the imparting of information. Groups such as Adult Survivors of Incest, Parents Anonymous, Gamblers Anonymous, Make Today Count (for cancer patients), Parents Without Partners, and Mended Hearts encourage the exchange of information among members and often invite experts to address the group.29 The group environment in which learning takes place is important. The ideal context is one of partnership and collaboration, rather than prescription and subordination.

Recent group therapy literature abounds with descriptions of specialized groups for individuals who have some specific disorder or face some definitive life crisis—for example, panic disorder,30 obesity,31 bulimia,32 adjustment after divorce, 33 herpes,34

coronary heart disease,35 parents of sexually abused children,36 male batterers,37

bereavement,38 HIV/AIDS,39 sexual dysfunction,40 rape,41 self-image adjustment after mastectomy,42 chronic pain,43 organ transplant,44 and prevention of depression relapse.45

In addition to offering mutual support, these groups generally build in a psychoeducational component approach offering explicit instruction about the nature of a client’s illness or life situation and examining clients’ misconceptions and self-defeating responses to their illness. For example, the leaders of a group for clients with panic disorder describe the physiological cause of panic attacks, explaining that heightened stress and arousal increase the flow of adrenaline, which may result in hyperventilation,

shortness of breath, and dizziness; the client misinterprets the symptoms in ways that only exacerbate them (“I’m dying” or “I’m going crazy”), thus perpetuating a vicious circle. The therapists discuss the benign nature of panic attacks and offer instruction first on how to bring on a mild attack and then on how to prevent it. They provide detailed instruction on proper breathing techniques and progressive muscular relaxation.

Groups are often the setting in which new mindfulness- and meditation-based stress reduction approaches are taught. By applying disciplined focus, members learn to become clear, accepting, and nonjudgmental observers of their thoughts and feelings and to reduce stress, anxiety, and vulnerability to depression.46

Leaders of groups for HIV-positive clients frequently offer considerable illness-related medical information and help correct members’ irrational fears and misconceptions about infectiousness. They may also advise members about methods of informing others of their condition and fashioning a less guilt-provoking lifestyle.

Leaders of bereavement groups may provide information about the natural cycle of bereavement to help members realize that there is a sequence of pain through which they are progressing and there will be a natural, almost inevitable, lessening of their distress as they move through the stages of this sequence. Leaders may help clients anticipate, for example, the acute anguish they will feel with each significant date (holidays, anniversaries, and birthdays) during the first year of bereavement. Psychoeducational groups for women with primary breast cancer provide members with information about their illness, treatment options, and future risks as well as recommendations for a healthier lifestyle. Evaluation of the outcome of these groups shows that participants demonstrate significant and enduring psychosocial benefits.47

Most group therapists use some form of anticipatory guidance for clients about to enter the frightening situation of the psychotherapy group, such as a preparatory session intended to clarify important reasons for psychological dysfunction and to provide instruction in methods of self-exploration.48 By predicting clients’ fears, by providing them with a cognitive structure, we help them cope more effectively with the culture shock they may encounter when they enter the group therapy (see chapter 10).

Didactic instruction has thus been employed in a variety of fashions in group therapy: to transfer information, to alter sabotaging thought patterns, to structure the group, to explain the process of illness. Often such instruction functions as the initial binding force in the group, until other therapeutic factors become operative. In part, however, explanation and clarification function as effective therapeutic agents in their own right. Human beings have always abhorred uncertainty and through the ages have sought to order the universe by providing explanations, primarily religious or scientific. The explanation of a phenomenon is the first step toward its control. If a volcanic eruption is caused by a displeased god, then at least there is hope of pleasing the god.

Frieda Fromm-Reichman underscores the role of uncertainty in producing anxiety. The awareness that one is not one’s own helmsman, she points out, that one’s perceptions and behavior are controlled by irrational forces, is itself a common and fundamental source of

anxiety.49

Our contemporary world is one in which we are forced to confront fear and anxiety often. In particular, the events of September 11, 2001, have brought these troubling emotions more clearly to the forefront of people’s lives. Confronting traumatic anxieties with active coping (for instance, engaging in life, speaking openly, and providing mutual support), as opposed to withdrawing in demoralized avoidance, is enormously helpful. These responses not only appeal to our common sense but, as contemporary neurobiological research demonstrates, these forms of active coping activate important neural circuits in the brain that help regulate the body’s stress reactions.50

And so it is with psychotherapy clients: fear and anxiety that stem from uncertainty of the source, meaning, and seriousness of psychiatric symptoms may so compound the total dysphoria that effective exploration becomes vastly more difficult. Didactic instruction, through its provision of structure and explanation, has intrinsic value and deserves a place in our repertoire of therapeutic instruments (see chapter 5).

Direct Advice

Unlike explicit didactic instruction from the therapist, direct advice from the members occurs without exception in every therapy group. In dynamic interactional therapy groups, it is invariably part of the early life of the group and occurs with such regularity that it can be used to estimate a group’s age. If I observe or hear a tape of a group in which the clients with some regularity say things like, “I think you ought to …” or “What you should do is …” or “Why don’t you … ?” then I can be reasonably certain either that the group is young or that it is an older group facing some difficulty that has impeded its development or effected temporary regression. In other words, advice-giving may reflect a resistance to more intimate engagement in which the group members attempt to manage relationships rather than to connect. Although advice-giving is common in early interactional group therapy, it is rare that specific advice will directly benefit any client. Indirectly, however, advice-giving serves a purpose; the process of giving it, rather than the content of the advice, may be beneficial, implying and conveying, as it does, mutual interest and caring.

Advice-giving or advice-seeking behavior is often an important clue in the elucidation of interpersonal pathology. The client who, for example, continuously pulls advice and suggestions from others, ultimately only to reject them and frustrate others, is well known to group therapists as the “help-rejecting complainer” or the “yes … but” client (see chapter 13).51 Some group members may bid for attention and nurturance by asking for suggestions about a problem that either is insoluble or has already been solved. Others soak up advice with an unquenchable thirst, yet never reciprocate to others who are equally needy. Some group members are so intent on preserving a high-status role in the group or a facade of cool self-sufficiency that they never ask directly for help; some are so anxious to please that they never ask for anything for themselves; some are excessively effusive in their gratitude; others never acknowledge the gift but take it home, like a bone, to gnaw on privately.

Other types of more structured groups that do not focus on member interaction make explicit and effective use of direct suggestions and guidance. For example, behavior- shaping groups, hospital discharge planning and transition groups, life skills groups, communicational skills groups, Recovery, Inc., and Alcoholics Anonymous all proffer considerable direct advice. One communicational skills group for clients who have chronic psychiatric illnesses reports excellent results with a structured group program that includes focused feedback, videotape playback, and problem-solving projects.52 AA makes use of guidance and slogans: for example, members are asked to remain abstinent for only the next twenty-four hours—“One day at a time.” Recovery, Inc. teaches members how to spot neurotic symptoms, how to erase and retrace, how to rehearse and reverse, and how to apply willpower effectively.

Is some advice better than others? Researchers who studied a behavior-shaping group of male sex offenders noted that advice was common and was useful to different members to different extents. The least effective form of advice was a direct suggestion; most effective was a series of alternative suggestions about how to achieve a desired goal.53 Psychoeducation about the impact of depression on family relationships is much more effective when participants examine, on a direct, emotional level, the way depression is affecting their own lives and family relationships. The same information presented in an intellectualized and detached manner is far less valuable.54

ALTRUISM

There is an old Hasidic story of a rabbi who had a conversation with the Lord about Heaven and Hell. “I will show you Hell,” said the Lord, and led the rabbi into a room containing a group of famished, desperate people sitting around a large, circular table. In the center of the table rested an enormous pot of stew, more than enough for everyone. The smell of the stew was delicious and made the rabbi’s mouth water. Yet no one ate. Each diner at the table held a very long-handled spoon—long enough to reach the pot and scoop up a spoonful of stew, but too long to get the food into one’s mouth. The rabbi saw that their suffering was indeed terrible and bowed his head in compassion. “Now I will show you Heaven,” said the Lord, and they entered another room, identical to the first— same large, round table, same enormous pot of stew, same long-handled spoons. Yet there was gaiety in the air; everyone appeared well nourished, plump, and exuberant. The rabbi could not understand and looked to the Lord. “It is simple,” said the Lord, “but it requires a certain skill. You see, the people in this room have learned to feed each other!”c

In therapy groups, as well as in the story’s imagined Heaven and Hell, members gain through giving, not only in receiving help as part of the reciprocal giving-receiving sequence, but also in profiting from something intrinsic to the act of giving. Many psychiatric patients beginning therapy are demoralized and possess a deep sense of having nothing of value to offer others. They have long considered themselves as burdens, and

the experience of finding that they can be of importance to others is refreshing and boosts self-esteem. Group therapy is unique in being the only therapy that offers clients the opportunity to be of benefit to others. It also encourages role versatility, requiring clients to shift between roles of help receivers and help providers.55

And, of course, clients are enormously helpful to one another in the group therapeutic process. They offer support, reassurance, suggestions, insight; they share similar problems with one another. Not infrequently group members will accept observations from another member far more readily than from the group therapist. For many clients, the therapist remains the paid professional; the other members represent the real world and can be counted on for spontaneous and truthful reactions and feedback. Looking back over the course of therapy, almost all group members credit other members as having been important in their improvement. Sometimes they cite their explicit support and advice, sometimes their simply having been present and allowing their fellow members to grow as a result of a facilitative, sustaining relationship. Through the experience of altruism, group members learn firsthand that they have obligations to those from whom they wish to receive care.

An interaction between two group members is illustrative. Derek, a chronically anxious and isolated man in his forties who had recently joined the group, exasperated the other members by consistently dismissing their feedback and concern. In response, Kathy, a thirty-five-year-old woman with chronic depression and substance abuse problems, shared with him a pivotal lesson in her own group experience. For months she had rebuffed the concern others offered because she felt she did not merit it. Later, after others informed her that her rebuffs were hurtful to them, she made a conscious decision to be more receptive to gifts offered her and soon observed, to her surprise, that she began to feel much better. In other words, she benefited not only from the support received but also in her ability to help others feel they had something of value to offer. She hoped that Derek could consider those possibilities for himself.

Altruism is a venerable therapeutic factor in other systems of healing. In primitive cultures, for example, a troubled person is often given the task of preparing a feast or performing some type of service for the community.56 Altruism plays an important part in the healing process at Catholic shrines, such as Lourdes, where the sick pray not only for themselves but also for one another. People need to feel they are needed and useful. It is commonplace for alcoholics to continue their AA contacts for years after achieving complete sobriety; many members have related their cautionary story of downfall and subsequent reclamation at least a thousand times and continually enjoy the satisfaction of offering help to others.

Neophyte group members do not at first appreciate the healing impact of other members. In fact, many prospective candidates resist the suggestion of group therapy with the question “How can the blind lead the blind?” or “What can I possibly get from others who are as confused as I am? We’ll end up pulling one another down.” Such resistance is best worked through by exploring a client’s critical self-evaluation. Generally, an individual who deplores the prospect of getting help from other group members is really

saying, “I have nothing of value to offer anyone.”

There is another, more subtle benefit inherent in the altruistic act. Many clients who complain of meaninglessness are immersed in a morbid self-absorption, which takes the form of obsessive introspection or a teeth-gritting effort to actualize oneself. I agree with Victor Frankl that a sense of life meaning ensues but cannot be deliberately pursued: life meaning is always a derivative phenomenon that materializes when we have transcended ourselves, when we have forgotten ourselves and become absorbed in someone (or something) outside ourselves.57 A focus on life meaning and altruism are particularly important components of the group psychotherapies provided to patients coping with life- threatening medical illnesses such as cancer and AIDS.†58

THE CORRECTIVE RECAPITULATION OF THE PRIMARY FAMILY GROUP

The great majority of clients who enter groups—with the exception of those suffering from posttraumatic stress disorder or from some medical or environmental stress—have a background of a highly unsatisfactory experience in their first and most important group: the primary family. The therapy group resembles a family in many aspects: there are authority /parental figures, peer/sibling figures, deep personal revelations, strong emotions, and deep intimacy as well as hostile, competitive feelings. In fact, therapy groups are often led by a male and female therapy team in a deliberate effort to simulate the parental configuration as closely as possible. Once the initial discomfort is overcome, it is inevitable that, sooner or later, the members will interact with leaders and other members in modes reminiscent of the way they once interacted with parents and siblings.

If the group leaders are seen as parental figures, then they will draw reactions associated with parental/authority figures: some members become helplessly dependent on the leaders, whom they imbue with unrealistic knowledge and power; other blindly defy the leaders, who are perceived as infantilizing and controlling; others are wary of the leaders, who they believe attempt to strip members of their individuality; some members try to split the co-therapists in an attempt to incite parental disagreements and rivalry; some disclose most deeply when one of the co-therapists is away; some compete bitterly with other members, hoping to accumulate units of attention and caring from the therapists; some are enveloped in envy when the leader’s attention is focused on others: others expend energy in a search for allies among the other members, in order to topple the therapists; still others neglect their own interests in a seemingly selfless effort to appease the leaders and the other members.

Obviously, similar phenomena occur in individual therapy, but the group provides a vastly greater number and variety of recapitulative possibilities. In one of my groups, Betty, a member who had been silently pouting for a couple of meetings, bemoaned the fact that she was not in one-to-one therapy. She claimed she was inhibited because she

knew the group could not satisfy her needs. She knew she could speak freely of herself in a private conversation with the therapist or with any one of the members. When pressed, Betty expressed her irritation that others were favored over her in the group. For example, the group had recently welcomed another member who had returned from a vacation, whereas her return from a vacation went largely unnoticed by the group. Furthermore, another group member was praised for offering an important interpretation to a member, whereas she had made a similar statement weeks ago that had gone unnoticed. For some time, too, she had noticed her growing resentment at sharing the group time; she was impatient while waiting for the floor and irritated whenever attention was shifted away from her.

Was Betty right? Was group therapy the wrong treatment for her? Absolutely not! These very criticisms—which had roots stretching down into her early relationships with her siblings—did not constitute valid objections to group therapy. Quite the contrary: the group format was particularly valuable for her, since it allowed her envy and her craving for attention to surface. In individual therapy—where the therapist attends to the client’s every word and concern, and the individual is expected to use up all the allotted time— these particular conflicts might emerge belatedly, if at all.

What is important, though, is not only that early familial conflicts are relived but that they are relived correctively. Reexposure without repair only makes a bad situation worse. Growth-inhibiting relationship patterns must not be permitted to freeze into the rigid, impenetrable system that characterizes many family structures. Instead, fixed roles must be constantly explored and challenged, and ground rules that encourage the investigation of relationships and the testing of new behavior must be established. For many group members, then, working out problems with therapists and other members is also working through unfinished business from long ago. (How explicit the working in the past need be is a complex and controversial issue, which I will address in chapter 5.)

DEVELOPMENT OF SOCIALIZING TECHNIQUES

Social learning—the development of basic social skills—is a therapeutic factor that operates in all therapy groups, although the nature of the skills taught and the explicitness of the process vary greatly, depending on the type of group therapy. There may be explicit emphasis on the development of social skills in, for example, groups preparing hospitalized patients for discharge or adolescent groups. Group members may be asked to role-play approaching a prospective employer or asking someone out on a date.

In other groups, social learning is more indirect. Members of dynamic therapy groups, which have ground rules encouraging open feedback, may obtain considerable information about maladaptive social behavior. A member may, for example, learn about a disconcerting tendency to avoid looking at the person with whom he or she is conversing; about others’ impressions of his or her haughty, regal attitude; or about a variety of other

social habits that, unbeknownst to the group member, have been undermining social relationships. For individuals lacking intimate relationships, the group often represents the first opportunity for accurate interpersonal feedback. Many lament their inexplicable loneliness: group therapy provides a rich opportunity for members to learn how they contribute to their own isolation and loneliness.59

One man, for example, who had been aware for years that others avoided social contact with him, learned in the therapy group that his obsessive inclusion of minute, irrelevant details in his social conversation was exceedingly off-putting. Years later he told me that one of the most important events of his life was when a group member (whose name he had long since forgotten) told him, “When you talk about your feelings, I like you and want to get closer; but when you start talking about facts and details, I want to get the hell out of the room!”

I do not mean to oversimplify; therapy is a complex process and obviously involves far more than the simple recognition and conscious, deliberate alteration of social behavior. But, as I will show in chapter 3, these gains are more than fringe benefits; they are often instrumental in the initial phases of therapeutic change. They permit the clients to understand that there is a huge discrepancy between their intent and their actual impact on others.†

Frequently senior members of a therapy group acquire highly sophisticated social skills: they are attuned to process (see chapter 6); they have learned how to be helpfully responsive to others; they have acquired methods of conflict resolution; they are less likely to be judgmental and are more capable of experiencing and expressing accurate empathy. These skills cannot but help to serve these clients well in future social interactions, and they constitute the cornerstones of emotional intelligence.60

IMITATIVE BEHAVIOR

Clients during individual psychotherapy may, in time, sit, walk, talk, and even think like their therapists. There is considerable evidence that group therapists influence the communicational patterns in their groups by modeling certain behaviors, for example, self-disclosure or support.61 In groups the imitative process is more diffuse: clients may model themselves on aspects of the other group members as well as of the therapist. 62 Group members learn from watching one another tackle problems. This may be particularly potent in homogeneous groups that focus on shared problems—for example, a cognitive-behavior group that teaches psychotic patients strategies to reduce the intensity of auditory hallucinations.63

The importance of imitative behavior in the therapeutic process is difficult to gauge, but social-psychological research suggests that therapists may have underestimated it. Bandura, who has long claimed that social learning cannot be adequately explained on the

basis of direct reinforcement, has experimentally demonstrated that imitation is an effective therapeutic force.†64 In group therapy it is not uncommon for a member to benefit by observing the therapy of another member with a similar problem constellation —a phenomenon generally referred to as vicarious or spectator therapy.65

Imitative behavior generally plays a more important role in the early stages of a group, as members identify with more senior members or therapists. 66 Even if imitative behavior is, in itself, short-lived, it may help to unfreeze the individual enough to experiment with new behavior, which in turn can launch an adaptive spiral (see chapter 4). In fact, it is not uncommon for clients throughout therapy to “try on,” as it were, bits and pieces of other people and then relinquish them as ill fitting. This process may have solid therapeutic impact; finding out what we are not is progress toward finding out what we are.

Chapter 2

INTERPERSONAL LEARNING Interpersonal learning, as I define it, is a broad and complex therapeutic factor. It is the group therapy analogue of important therapeutic factors in individual therapy such as insight, working through the transference, and the corrective emotional experience. But it also represents processes unique to the group setting that unfold only as a result of specific work on the part of the therapist. To define the concept of interpersonal learning and to describe the mechanism whereby it mediates therapeutic change in the individual, I first need to discuss three other concepts:

1. The importance of interpersonal relationships

2. The corrective emotional experience

3. The group as social microcosm

THE IMPORTANCE OF INTERPERSONAL RELATIONSHIPS

From whatever perspective we study human society—whether we scan humanity’s broad evolutionary history or scrutinize the development of the single individual—we are at all times obliged to consider the human being in the matrix of his or her interpersonal relationships. There is convincing data from the study of nonhuman primates, primitive human cultures, and contemporary society that human beings have always lived in groups that have been characterized by intense and persistent relationships among members and that the need to belong is a powerful, fundamental, and pervasive motivation.1 Interpersonal relatedness has clearly been adaptive in an evolutionary sense: without deep, positive, reciprocal interpersonal bonds, neither individual nor species survival would have been possible.

John Bowlby, from his studies of the early mother-child relationship, concludes not only that attachment behavior is necessary for survival but also that it is core, intrinsic, and genetically built in.2 If mother and infant are separated, both experience marked anxiety concomitant with their search for the lost object. If the separation is prolonged, the consequences for the infant will be profound. Winnicott similarly noted, “There is no such thing as a baby. There exists a mother-infant pair.”3 We live in a “relational matrix,” according to Mitchell: “The person is comprehensible only within this tapestry of relationships, past and present.”4

Similarly, a century ago the great American psychologist-philosopher William James said:

We are not only gregarious animals liking to be in sight of our fellows, but we have an innate propensity to get ourselves noticed, and noticed favorably, by our kind. No more fiendish punishment could be devised, were such a thing physically possible, than that one should be turned loose in society and remain absolutely unnoticed by all the members thereof.5

Indeed, James’s speculations have been substantiated time and again by contemporary research that documents the pain and the adverse consequences of loneliness. There is, for example, persuasive evidence that the rate for virtually every major cause of death is significantly higher for the lonely, the single, the divorced, and the widowed.6 Social isolation is as much a risk factor for early mortality as obvious physical risk factors such as smoking and obesity.7 The inverse is also true: social connection and integration have a positive impact on the course of serious illnesses such as cancer and AIDS.8

Recognizing the primacy of relatedness and attachment, contemporary models of dynamic psychotherapy have evolved from a drive-based, one-person Freudian psychology to a two-person relational psychology that places the client’s interpersonal experience at the center of effective psychotherapy. †9 Contemporary psychotherapy employs “a relational model in which mind is envisioned as built out of interactional configurations of self in relation to others.”10

Building on the earlier contributions of Harry Stack Sullivan and his interpersonal theory of psychiatry,11 interpersonal models of psychotherapy have become prominent.12 Although Sullivan’s work was seminally important, contemporary generations of therapists rarely read him. For one thing, his language is often obscure (though there are excellent renderings of his work into plain English);13 for another, his work has so pervaded contemporary psychotherapeutic thought that his original writings seem overly familiar or obvious. However, with the recent focus on integrating cognitive and interpersonal approaches in individual therapy and in group therapy, interest in his contributions have resurged.14 Kiesler argues in fact that the interpersonal frame is the most appropriate model within which therapists can meaningfully synthesize cognitive, behavioral, and psychodynamic approaches—it is the most comprehensive of the integrative psychotherapies.†15

Sullivan’s formulations are exceedingly helpful for understanding the group therapeutic process. Although a comprehensive discussion of interpersonal theory is beyond the scope of this book, I will describe a few key concepts here. Sullivan contends that the personality is almost entirely the product of interaction with other significant human beings. The need to be closely related to others is as basic as any biological need and is, in the light of the prolonged period of helpless infancy, equally necessary to survival. The developing child, in the quest for security, tends to cultivate and to emphasize those traits and aspects of the self that meet with approval and to squelch or deny those that meet with disapproval. Eventually the individual develops a concept of the self based on these perceived appraisals of significant others.

The self may be said to be made up of reflected appraisals. If these were chiefly

derogatory, as in the case of an unwanted child who was never loved, of a child who has fallen into the hands of foster parents who have no real interest in him as a child; as I say, if the self-dynamism is made up of experience which is chiefly derogatory, it will facilitate hostile, disparaging appraisals of other people and it will entertain disparaging and hostile appraisals of itself.16

This process of constructing our self-regard on the basis of reflected appraisals that we read in the eyes of important others continues, of course, th

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