The Theory and Practice of Group Psychotherapy (3 page)

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 the 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
.

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

D
oes 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.
^a
10

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