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 s

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 thera

equence 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 thera

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