The Theory and Practice of Group Psychotherapy (14 page)

For the most part, the disturbed interpersonal skills of our clients have limited their opportunities for effective sharing and acceptance in intimate relationships. Furthermore, some members are convinced that their abhorrent impulses and fantasies shamefully bar them from social interaction. † I have known many isolated clients for whom the group represented their only deeply human contact. After just a few sessions, they have a stronger sense of being at home in the group than anywhere else. Later, even years afterward, when most other recollections of the group have faded from memory, they may still remember the warm sense of belonging and acceptance.

As one successful client looking back over two and a half years of therapy put it, “The most important thing in it was just having a group there, people that I could always talk to, that wouldn’t walk out on me. There was so much caring and hating and loving in the group, and I was a part of it. I’m better now and have my own life, but it’s sad to think that the group’s not there anymore.”

Furthermore, group members see that they are not just passive beneficiaries of group cohesion, they also generate that cohesion, creating durable relationships—perhaps for the first time in their lives. One group member commented that he had always attributed his aloneness to some unidentified, intractable, repugnant character failing. It was only after he stopped missing meetings regularly because of his discouragement and sense of futility that he discovered the responsibility he exercised for his own aloneness: relationships do not inevitably wither—his had been doomed largely by his choice to neglect them.

Some individuals internalize the group: “It’s as though the group is sitting on my shoulder, watching me. I’m forever asking, ‘What would the group say about this or that?’” Often therapeutic changes persist and are consolidated because, even years later, the members are disinclined to let the group down.
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Membership, acceptance, and approval in various groups are of the utmost importance in the individual’s developmental sequence. The importance of belonging to childhood peer groups, adolescent cliques, sororities or fraternities, or the proper social “in” group can hardly be overestimated. Nothing seems to be of greater importance for the self-esteem and well-being of the adolescent, for example, than to be included and accepted in some social group, and nothing is more devastating than exclusion.
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Most of our clients, however, have an impoverished group history; they have never been valuable and integral to a group. For these individuals, the sheer successful negotiation of a group experience may
in itself
be curative. Belonging in the group raises self-esteem and meets members’ dependency needs but in ways that also foster responsibility and autonomy, as each member contributes to the group’s welfare and internalizes the atmosphere of a cohesive group.
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Thus, in a number of ways, members of a therapy group come to mean a great deal to one another. The therapy group, at first perceived as an artificial group that does not count, may in fact come to count very much. I have known groups whose members experience together severe depressions, psychoses, marriage, divorce, abortions, suicide, career shifts, sharing of innermost thoughts, and incest (sexual activity among the group members). I have seen a group physically carry one of its members to the hospital and seen many groups mourn the death of members. I have seen members of cancer support groups deliver eulogies at the funeral of a fallen group member. Relationships are often cemented by moving or hazardous adventures. How many relationships in life are so richly layered?

Evidence

Empirical evidence for the impact of group cohesiveness is not as extensive or as systematic as research documenting the importance of relationship in individual psychotherapy. Studying the effect of cohesiveness is more complex
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because it involves research on variables closely related to cohesion such as group climate (the degree of engagement, avoidance, and conflict in the group)
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and alliance (the member-therapist relationship).
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The results of the research from all these perspectives, however, point to the same conclusion: relationship is at the heart of good therapy. This is no less important in the era of managed care and third-party oversight than it was in the past. In fact, the contemporary group therapist has an even larger responsibility to safeguard the therapeutic relationship from external intrusion and control.
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I now turn to a survey of the relevant research on cohesion. (Readers who are less interested in research methodology may wish to proceed directly to the summary section.)

• In an early study of former group psychotherapy clients in which members’ explanations of the therapeutic factors in their therapy were transcribed and categorized, investigators found that more than half considered mutual support the primary mode of help in group therapy. Clients who perceived their group as cohesive attended more sessions, experienced more social contact with other members, and felt that the group had been therapeutic. Improved clients were significantly more likely to have felt accepted by the other members and to mention particular individuals when queried about their group experience.
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• In 1970, I reported a study in which successful group therapy clients were asked to look back over their experience and to rate, in order of effectiveness, the series of therapeutic factors I describe in this book.
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Since that time, a vast number of studies using analogous designs have generated considerable data on clients’ views of what aspects of group therapy have been most useful. I will examine these results in depth in the next chapter; for now, it is sufficient to note that there is a strong consensus that clients regard group cohesiveness as an extremely important determinant of successful group therapy.

• In a six-month study of two long-term therapy groups,
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observers rated the process of each group session by scoring each member on five variables: acceptance, activity, desensitivity, abreaction, and improvement. Weekly self-ratings were also obtained from each member. Both the research raters and group members considered “acceptance” to be the variable most strongly related to improvement.

• Similar conclusions were reached in a study of forty-seven clients in twelve psychotherapy groups. Members’ self-perceived personality change correlated significantly with both their feelings of involvement in the group and their assessment of total group cohesiveness.
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• My colleagues and I evaluated the one-year outcome of all forty clients who had started therapy in five outpatient groups.
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Outcome was then correlated with variables measured in the first three months of therapy. Positive outcome in therapy significantly correlated with only two predictor variables: group cohesiveness
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and general popularity—that is, clients who, early in the course of therapy, were most attracted to the group (high cohesiveness) and who were rated as more popular by the other group members at the sixth and the twelfth weeks had a better therapy outcome at the fiftieth week. The popularity finding, which in this study correlated even more positively with outcome than did cohesiveness, is, as I shall discuss shortly, relevant to group cohesiveness and sheds light on the mechanism through which group cohesiveness mediates change.

• The same findings emerge in more structured groups. A study of fifty-one clients who attended ten sessions of behavioral group therapy demonstrated that “attraction to the group” correlated significantly with improved self-esteem and inversely correlated with the group dropout rate.
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• The quality of intermember relationships has also been well documented as an essential ingredient in T-groups (also called sensitivity-training, process, encounter, or experiential groups; see chapter 16). A rigorously designed study found a significant relationship between the quality of intermember relationships and outcome in a T-group of eleven subjects who met twice a week for a total of sixty-four hours.
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The members who entered into the most two-person mutually therapeutic relationships showed the most improvement during the course of the group.
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Furthermore, the perceived relationship with the group leader was unrelated to the extent of change.

• My colleagues M. A. Lieberman, M. Miles, and I conducted a study of 210 subjects in eighteen encounter groups, encompassing ten ideological schools (gestalt, transactional analysis, T-groups, Synanon, personal growth, Esalen, psychoanalytic, marathon, psychodrama, encounter tape).
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(See chapter 16 for a detailed discussion of this project.) Cohesiveness was assessed in several ways and correlated with outcome.
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The results indicated that attraction to the group is indeed a powerful determinant of outcome. All methods of determining cohesiveness demonstrated a positive correlation between cohesiveness and outcome. A member who experienced little sense of belongingness or attraction to the group, even measured early in the course of the sessions, was unlikely to benefit from the group and, in fact, was likely to have a negative outcome. Furthermore, the groups with the higher overall levels of cohesiveness had a significantly better total outcome than groups with low cohesiveness.

• Another large study (N = 393) of experiential training groups yielded a strong relationship between affiliativeness (a construct that overlaps considerably with cohesion) and outcome.
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• MacKenzie and Tschuschke, studying twenty clients in long-term inpatient groups, differentiated members’ personal “emotional relatedness to the group” from their appraisal of “group work” as a whole. The individual’s personal sense of belonging correlated with future outcome, whereas the total group work scales did not.
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• S. Budman and his colleagues developed a scale to measure cohesiveness via observations by trained raters of videotaped group sessions. They studied fifteen therapy groups and found greater reductions in psychiatric symptoms and improvement in self-esteem in the most cohesively functioning groups. Group cohesion that was evident early—within the first thirty minutes of each session—predicted better outcome.
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• A number of other studies have examined the role of the relationship between the client and the group leader in group therapy. Marziali and colleagues
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examined group cohesion and the client-group leader relationship in a thirty-session manualized interpersonal therapy group of clients with borderline personality disorder. Cohesion and member-leader relationship correlated strongly, supporting Budman’s findings,
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and both positively correlated with outcome. However, the member-group leader relationship measure was a more powerful predictor of outcome. The relationship between client and therapist may be particularly important for clients who have volatile interpersonal relationships and with whom the therapist serves an important containing function.

• In a study of a short-term structured cognitive-behavioral therapy group for social phobia
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the relationship with the therapist deepened over the twelve weeks of treatment and correlated positively with outcome, but cohesion was static and not related to outcome. In this study the group was a setting for therapy and not an agent of therapy. Intermember bonds were not cultivated by the therapists, leading the authors to conclude that in highly structured groups, what matters most is the client-therapist collaboration around the therapy tasks.
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• A study of thirty-four clients with depression and social isolation treated in a twelve-session interactional problem-solving group reported that clients who described experiencing warmth and positive regard from the group leader had better therapy outcomes. The opposite also held true. Negative therapy outcomes were associated with negative client–group leader relationships. This correlative study does not address cause and effect, however: Are clients better liked by their therapist because they do well in therapy, or does being well liked promote more well-being and effort?
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• Outcomes in brief intensive American Group Psychotherapy Association Institute training groups were influenced by higher levels of engagement.
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Positive outcomes may well be mediated by group engagement that fosters more interpersonal communication and self-disclosure.
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Summary

I have cited evidence that group members value deeply the acceptance and support they receive from their therapy group. Self-perceived therapy outcome is positively correlated with attraction to the group. Highly cohesive groups have a better overall outcome than groups with low esprit de corps. Both emotional connectedness and the experience of group effectiveness contribute to group cohesiveness. Individuals with positive outcomes have had more mutually satisfying relationships with other members. Highly cohesive groups have greater levels of self-disclosure. For some clients and some groups (especially highly structured groups) the relationship with the leader may be the essential factor. A strong therapeutic relationship may not guarantee a positive outcome, but a poor therapeutic relationship will certainly not result in an effective treatment.