The Theory and Practice of Group Psychotherapy (15 page)

The presence of cohesion early in each session as well as in the early sessions of the group correlates with positive outcomes. It is critical that groups become cohesive and that leaders be alert to each member’s personal experience of the group and address problems with cohesion quickly. Positive client outcome is also correlated with group popularity, a variable closely related to group support and acceptance. Although therapeutic change is multidimensional, these findings taken together strongly support the contention that group cohesiveness is an important determinant of positive therapeutic outcome.

In addition to this direct evidence, there is considerable indirect evidence from research with other types of groups. A plethora of studies demonstrate that in laboratory task groups, high levels of group cohesiveness produce many results that may be considered intervening therapy outcome factors. For example, group cohesiveness results in better group attendance, greater participation of members, greater influenceability of members, and many other effects. I will consider these findings in detail shortly, as I discuss the mechanism by which cohesiveness fosters therapeutic change.

MECHANISM OF ACTION

How do group acceptance, group support, and trust help troubled individuals? Surely there must be more to it than simple support or acceptance; therapists learn early in their careers that love is not enough. Although the quality of the therapist-client relationship is crucial, the therapist must do more than simply relate warmly and honestly to the client.
⁵²
The therapeutic relationship creates favorable conditions for setting other processes in motion. What other processes? And how are they important?

Carl Rogers’s deep insights into the therapeutic relationship are as relevant today as they were nearly fifty years ago. Let us start our investigation by examining his views about the mode of action of the therapeutic relationship in individual therapy. In his most systematic description of the process of therapy, Rogers states that when the conditions of an ideal therapist-client relationship exist, the following characteristic process is set into motion:

1. The client is increasingly free in expressing his feelings.

2. He begins to test reality and to become more discriminatory in his feelings and perceptions of his environment, his self, other persons, and his experiences.

3. He increasingly becomes aware of the incongruity between his experiences and his concept of self.

4. He also becomes aware of feelings that have been previously denied or distorted in awareness.

5. His concept of self, which now includes previously distorted or denied aspects, becomes more congruent with his experience.

6. He becomes increasingly able to experience, without threat, the therapist’s unconditional positive regard and to feel an unconditional positive self-regard.

7. He increasingly experiences himself as the focus of evaluation of the nature and worth of an object or experience.

8. He reacts to experience less in terms of his perception of others’ evaluation of him and more in terms of its effectiveness in enhancing his own development.
⁵³

Central to Rogers’s views is his formulation of an actualizing tendency, an inherent tendency in all life to expand and to develop itself—a view stretching back to early philosophic views and clearly enunciated a century ago by Nietzsche.
⁵⁴
It is the therapist’s task to function as a facilitator and to create conditions favorable for self-expansion. The first task of the individual is self-exploration: the examination of feelings and experiences previously denied awareness.

This task is a ubiquitous stage in dynamic psychotherapy. Horney, for example, emphasized the individual’s need for self-knowledge and self-realization, stating that the task of the therapist is to remove obstacles in the path of these autonomous processes.
⁵⁵
Contemporary models recognize the same principle. Clients often pursue therapy with a plan to disconfirm pathogenic beliefs that obstruct growth and development.
⁵⁶
In other words, there is a built-in inclination to growth and self-fulfillment in all individuals. The therapist does not have to inspirit clients with these qualities (as if we could!). Instead, our task is to remove the obstacles that block the process of growth. And one way we do this is by creating an ideal therapeutic atmosphere in the therapy group. A strong bond between members not only directly disconfirms one’s unworthiness, it also generates greater willingness among clients to self-disclose and take interpersonal risks. These changes help deactivate old, negative beliefs about the self in relation to the world.
⁵⁷

There is experimental evidence that good rapport in individual therapy and its equivalent (cohesiveness) in group therapy encourage the client to participate in a process of reflection and personal exploration. For example, Truax,
⁵⁸
studying forty-five hospitalized patients in three heterogeneous groups, demonstrated that participants in cohesive groups were significantly more inclined to engage in deep and extensive self-exploration.
⁵⁹
Other research demonstrates that high cohesion is closely related to high degrees of intimacy, risk taking, empathic listening, and feedback.
⁶⁰
The group members’ recognition that their group is working well at the task of interpersonal learning produces greater cohesion in a positive and self-reinforcing loop.
⁶¹
Success with the group task strengthens the emotional bonds in the group.

Perhaps cohesion is vital because many of our clients have not had the benefit of ongoing solid peer acceptance in childhood. Therefore they find validation by other group members a new and vital experience. Furthermore, acceptance and understanding among members may carry greater power and meaning than acceptance by a therapist. Other group members, after all, do not have to care, or understand. They’re not paid for it; it’s not their “job.”
⁶²

The intimacy developed in a group may be seen as a counterforce in a technologically driven culture that, in all ways—socially, professionally, residentially, recreationally—inexorably dehumanizes relationships.
⁶³
In a world in which traditional boundaries that maintain relationships are increasingly permeable and transient, there is a greater need than ever for group belonging and group identity.
⁶⁴
The deeply felt human experience in the group may be of great value to the individual, Rogers believes. Even if it creates no visible carryover, no external change in behavior, group members may still experience a more human, richer part of themselves and have this as an internal reference point. This last point is worth emphasizing, for it is one of those gains of therapy—especially group therapy—that enrich one’s interior life and yet may not, at least for a long period of time, have external behavioral manifestations and thus may elude measurement by researchers and consideration by managed health care administrators, who determine how much and what type of therapy is indicated.

Group members’ acceptance of self and acceptance of other members are interdependent; not only is self-acceptance basically dependent on acceptance by others, but acceptance of others is fully possible only after one can accept oneself. This principle is supported by both clinical wisdom and research.
⁶⁵
Members of a therapy group may experience considerable self-contempt and contempt for others. A manifestation of this feeling may be seen in the client’s initial refusal to join “a group of nuts” or reluctance to become closely involved with a group of pained individuals for fear of being sucked into a maelstrom of misery. A particularly evocative response to the prospect of group therapy was given by a man in his eighties when he was invited to join a group for depressed elderly men: it was useless, he said, to waste time watering a bunch of dead trees—his metaphor for the other men in his nursing home.
⁶⁶

In my experience, all individuals seeking assistance from a mental health professional have in common two paramount difficulties: (1) establishing and maintaining meaningful interpersonal relationships, and (2) maintaining a sense of personal worth (self-esteem). It is hard to discuss these two interdependent areas as separate entities, but since in the preceding chapter I dwelled more heavily on the establishment of interpersonal relationships, I shall now turn briefly to self-esteem.

Self-esteem and public esteem are highly interdependent.
⁶⁷
Self-esteem refers to an individual’s evaluation of what he or she is really worth, and is indissolubly linked to that person’s experiences in prior social relationships. Recall Sullivan’s statement: “The self may be said to be made up of reflected appraisals.”
⁶⁸
In other words, during early development, one’s perceptions of the attitudes of others toward oneself come to determine how one regards and values oneself. The individual internalizes many of these perceptions and, if they are consistent and congruent, relies on these internalized evaluations for some stable measure of self-worth.

But, in addition to this internal reservoir of self-worth, people are, to a greater or lesser degree, always concerned and influenced by the current evaluations of others—especially the evaluation provided by the groups to which they belong. Social psychology research supports this clinical understanding: the groups and relationships in which we take part become incorporated in the self.
⁶⁹
One’s attachment to a group is multidimensional. It is shaped both by the member’s degree of confidence in his attractiveness to the group—am I a desirable member?—and the member’s relative aspiration for affiliation—do I want to belong?

The influence of public esteem—that is, the group’s evaluation—on an individual depends on several factors: how important the person feels the group to be; the frequency and specificity of the group’s communications to the person about that public esteem; and the salience to the person of the traits in question. (Presumably, considering the honest and intense self-disclosure in therapy groups, the salience is very great indeed, since these traits are close to a person’s core identity.) In other words, the more the group matters to the person, and the more that person subscribes to the group values, the more he or she will be inclined to value and agree with the group judgment.
⁷⁰
This last point has much clinical relevance. The more attracted an individual is to the group, the more he or she will respect the judgment of the group and will attend to and take seriously any discrepancy between public esteem and self-esteem. A discrepancy between the two will create a state of dissonance, which the individual will attempt to correct.

Let us suppose this discrepancy veers to the negative side—that is, the group’s evaluation of the individual is less than the individual’s self-evaluation. How to resolve that discrepancy? One recourse is to deny or distort the group’s evaluation. In a therapy group, this is not a positive development, for a vicious circle is generated: the group, in the first place, evaluates the member poorly because he or she fails to participate in the group task (which in a therapy group consists of active exploration of one’s self and one’s relationships with others). Any increase in defensiveness and communicational problems will only further lower the group’s esteem of that particular member. A common method used by members to resolve such a discrepancy is to devalue the group—emphasizing, for example, that the group is artificial or composed of disturbed individuals, and then comparing it unfavorably to some anchor group (for example, a social or occupational group) whose evaluation of the member is different. Members who follow this sequence (for example, the group deviants described in chapter 8) usually drop out of the group.

Toward the end of a successful course of group therapy, one group member reviewed her early recollections of the group as follows: “For the longest time I told myself you were all nuts and your feedback to me about my defensiveness and inaccessibility was ridiculous. I wanted to quit—I’ve done that before many times, but I felt enough of a connection here to decide to stay. Once I made that choice I started to tell myself that you cannot all be wrong about me. That was the turning point in my therapy.” This is an example of the therapeutic method of resolving the discrepancy for the individual: that is, to raise one’s public esteem by changing those behaviors and attitudes that have been criticized by the group. This method is more likely if the individual is highly attracted to the group and if the public esteem is not too much lower than the self-esteem.

But is the use of group pressure to change individual behavior or attitudes a form of social engineering? Is it not mechanical? Does it not neglect deeper levels of integration? Indeed, group therapy does employ behavioral principles; psychotherapy is, in all its variants, basically a form of learning. Even the most nondirective therapists use, at an unconscious level, operant conditioning techniques: they signal desirable conduct or attitudes to clients, whether explicitly or subtly.
⁷¹

This process does not suggest that we assume an explicit behavioral, mechanistic view of the client, however. Aversive or operant conditioning of behavior and attitudes is, in my opinion, neither feasible nor effective when applied as an isolated technique. Although clients often report lasting improvement after some disabling complaint is remedied by behavioral therapy techniques, close inspection of the process invariably reveals that important interpersonal relationships have been affected. Either the therapist-client relationship in the behavioral and cognitive therapies has been more meaningful than the therapist realized (and research evidence substantiates this),
⁷²
or some important changes, initiated by the symptomatic relief, have occurred in the client’s social relationships that have served to reinforce and maintain the client’s improvement. Again, as I have stressed before, all the therapeutic factors are intricately interdependent. Behavior and attitudinal change, regardless of origin, begets other changes. The group changes its evaluation of a member; the member feels more self-satisfied in the group and with the group itself; and the adaptive spiral described in the previous chapter is initiated.