The Theory and Practice of Group Psychotherapy (16 page)

A far more common occurrence in a psychotherapy group is a discrepancy in the opposite direction: the group’s evaluation of a member is higher than the member’s self-evaluation. Once again, the member is placed in a state of dissonance and once again will attempt to resolve the discrepancy. What can a member in that position do? Perhaps the person will lower the public esteem by revealing personal inadequacies. However, in therapy groups, this behavior has the paradoxical effect of raising public esteem—disclosure of inadequacies is a valued group norm and enhances acceptance by the group. Another possible scenario, desirable therapeutically, occurs when group members reexamine and alter their low level of self-esteem. An illustrative clinical vignette will flesh out this formulation:

• Marietta, a thirty-four-year-old housewife with an emotionally impoverished background, sought therapy because of anxiety and guilt stemming from a series of extramarital affairs. Her self-esteem was exceedingly low; nothing escaped her self-excoriation: her physical appearance, her intelligence, her speech, her unimaginativeness, her functioning as a mother and a wife. Although she received solace from her religious affiliation, it was a mixed blessing because she felt too unworthy to socialize with the church people in her community. She married a man she considered repugnant but nonetheless a good man—certainly good enough for her. Only in her sexual affairs, particularly when she had them with several men at once, did she seem to come alive—to feel attractive, desirable, and able to give something of herself that seemed of value to others. However, this behavior clashed with her religious convictions and resulted in considerable anxiety and further self-derogation.

Viewing the group as a social microcosm, the therapist soon noted characteristic trends in Marietta’s group behavior. She spoke often of the guilt issuing from her sexual behavior, and for many hours the group struggled with all the titillating ramifications of her predicament. At all other times in the group, however, she disengaged and offered nothing. She related to the group as she did to her social environment. She could belong to it, but she could not really relate to the other people: the only thing of real interest she felt she could offer was her genitals.

Over time in the group she began to respond and to question others and to offer warmth, support, and feedback. She found other, nonsexual, aspects of herself to disclose and spoke openly of a broad array of her life concerns. Soon she found herself increasingly valued by the other members. She gradually reexamined and eventually disconfirmed her belief that she had little of value to offer. The discrepancy between her public esteem and her self-esteem widened (that is, the group valued her more than she regarded herself), and soon she was forced to entertain a more realistic and positive view of herself. Gradually, an adaptive spiral ensued: she began to establish meaningful nonsexual relationships both in and out of the group and these, in turn, further enhanced her self-esteem.

The more therapy disconfirms the client’s negative self-image through new relational experience, the more effective therapy will be.
⁷³

Self-Esteem, Public Esteem, and Therapeutic Change: Evidence

Group therapy research has not specifically investigated the relationship between public esteem and shifts in self-esteem. However, an interesting finding from a study of experiential groups (see chapter 16) was that members’ self-esteem decreased when public esteem decreased.
⁷⁴
(Public esteem is measured by sociometric data, which involves asking members to rank-order one another on several variables.) Researchers also discovered that the more a group member underestimated his or her public esteem, the more acceptable that member was to the other members. In other words, the ability to face one’s deficiencies, or even to judge oneself a little harshly, increases one’s public esteem. Humility, within limits, is far more adaptable than arrogance.

It is also interesting to consider data on group popularity, a variable closely related to public esteem. The group members considered most popular by other members after six and twelve weeks of therapy had significantly better therapy outcomes than the other members at the end of one year.
⁷⁵
Thus, it seems that clients who have high public esteem early in the course of a group are destined to have a better therapy outcome.

What factors seem to be responsible for the attainment of popularity in therapy groups? Three variables, which did not themselves correlate with outcome, correlated significantly with popularity:

1. Previous self-disclosure.
⁷⁶

2. Interpersonal compatibility:
⁷⁷
individuals who (perhaps fortuitously) have interpersonal needs that happen to blend well with those of the other group members become popular in the group.

3. Other sociometric measures; group members who were often chosen as leisure companions and worked well with colleagues became popular in the group. A clinical study of the most popular and least popular members revealed that popular members tended to be young, well-educated, intelligent, and introspective. They filled the leadership vacuum that occurs early in the group when the therapist declines to assume the traditional leader role.
⁷⁸

The most unpopular group members were rigid, moralistic, nonintrospective, and least involved in the group task. Some were blatantly deviant, attacking the group and isolating themselves. Some schizoid members were frightened of the group process and remained peripheral. A study of sixty-six group therapy members concluded that the less popular members (that is, those viewed less positively by other members) were more inclined to drop out of the group.
⁷⁹

Social psychology researchers have also investigated the attributes that confer higher social status in social groups. The personality attribute of extraversion (measured by a personality questionnaire, the NEO-PI)
⁸⁰
is a very strong predictor of popularity.
⁸¹
Extraversion connotes the traits of active and energetic social engagement, that is, a person who is upbeat and emotionally robust. Depue’s neurobiological research
⁸²
suggests that such individuals invite others to approach them. The promise of the extravert’s welcome response rewards and reinforces engagement.

The Lieberman, Yalom, and Miles encounter group study corroborated these conclusions.
⁸³
Sociometric data revealed that the members with the more positive outcomes were influential and engaged in behavior in close harmony with the encounter group values of risk taking, spontaneity, openness, self-disclosure, expressivity, group facilitation, and support. Evidence has emerged from both clinical and social-psychological small-group research demonstrating that the members who adhere most closely to group norms attain positions of popularity and influence.
⁸⁴
Members who help the group achieve its tasks are awarded higher status.
⁸⁵

To summarize: Members who are popular and influential in therapy groups have a higher likelihood of changing. They attain popularity and influence in the group by virtue of their active participation, self-disclosure, self-exploration, emotional expression, nondefensiveness, leadership, interest in others, and support of the group.

It is important to note that the individual who adheres to the group norms not only is rewarded by increased public esteem within the group but also uses those same social skills to deal more effectively with interpersonal problems outside the group. Thus, increased popularity in the group acts therapeutically in two ways: by augmenting self-esteem and by reinforcing adaptive social skills. The rich get richer. The challenge in group therapy is helping the poor get richer as well.

Group Cohesiveness and Group Attendance

Continuation in the group is obviously a necessary, though not a sufficient, prerequisite for successful treatment. Several studies indicate that clients who terminate early in the course of group therapy receive little benefit.
⁸⁶
In one study, over fifty clients who dropped out of long-term therapy groups within the first twelve meetings reported that they did so because of some stress encountered in the group. They were not satisfied with their therapy experience and they did not improve; indeed, many of these clients felt worse.
⁸⁷
Clients who remain in the group for at least several months have a high likelihood (85 percent in one study) of profiting from therapy.
⁸⁸

The greater a member’s attraction to the group, the more inclined that person will be to stay in therapy groups as well as in encounter groups, laboratory groups (formed for some research purpose), and task groups (established to perform some designated task).
⁸⁹
The Lieberman, Yalom, and Miles encounter group study discovered a high correlation between low cohesiveness and eventual dropping out from the group.
⁹⁰
The dropouts had little sense of belongingness and left the group most often because they felt rejected, attacked, or unconnected.

The relationship between cohesiveness and maintenance of membership has implications for the total group as well. Not only do the least cohesive members terminate membership and fail to benefit from therapy, but noncohesive groups with high member turnover prove to be less therapeutic for the remaining members as well. Clients who drop out challenge the group’s sense of worth and effectiveness.

Stability of membership is a necessary condition for effective shortand long-term interactional group therapy. Although most therapy groups go through an early phase of instability during which some members drop out and replacements are added, the groups thereafter settle into a long, stable phase in which much of the solid work of therapy occurs. Some groups seem to enter this phase of stability early, and other groups never achieve it. Dropouts at times beget other dropouts, as other clients may terminate soon after the departure of a key member. In a group therapy follow-up study, clients often spontaneously underscored the importance of membership stability.
⁹¹

In chapter 15, I will discuss the issue of cohesiveness in groups led in clinical settings that preclude a stable long-term membership. For example, drop-in crisis groups or groups on an acute inpatient ward rarely have consistent membership even for two consecutive meetings. In these clinical situations, therapists must radically alter their perspectives on the life development of the group. I believe, for example, that the appropriate life span for the acute inpatient group is a single session. The therapist must strive to be efficient and to offer effective help to as many members as possible during each single session.

Brief therapy groups pay a particularly high price for poor attendance, and therapists must make special efforts to increase cohesiveness early in the life of the group. These strategies (including strong pregroup preparation, homogeneous composition, and structured interventions)
⁹²
will be discussed in chapter 15.

Group Cohesiveness and the Expression of Hostility

It would be a mistake to equate cohesiveness with comfort. Although cohesive groups may show greater acceptance, intimacy, and understanding, there is evidence
that they also permit greater development and expression of hostility and conflict
. Cohesive groups have norms (that is, unwritten rules of behavior accepted by group members) that encourage open expression of disagreement or conflict alongside support. In fact, unless hostility can be openly expressed, persistent covert hostile attitudes may hamper the development of cohesiveness and effective interpersonal learning. Unexpressed hostility simply smolders within, only to seep out in many indirect ways, none of which facilitates the group therapeutic process. It is not easy to continue communicating honestly with someone you dislike or even hate. The temptation to avoid the other and to break off communication is very great; yet when channels of communication are closed, so are any hopes for conflict resolution and for personal growth.

This is as true on the megagroup—even the national—level as on the dyadic. The Robbers’ Cave experiment, a famed research project conducted long ago, in the infancy of group dynamics research,
^e
offers experimental evidence still relevant for contemporary clinical work.
⁹³
A camp of well-adjusted eleven-year-old boys was divided at the outset into two groups that were placed in competition with each other in a series of contests. Soon each group developed considerable cohesiveness as well as a deep sense of hostility toward the other group. Any meaningful communication between the two groups became impossible. If, for example, they were placed in physical proximity in the dining hall, the group boundaries remained impermeable. Intergroup communication consisted of taunts, insults, and spitballs.

How to restore meaningful communication between the members of the two groups? That was the quest of the researchers. Finally they hit upon a successful strategy. Intergroup hostility was relieved only when a sense of allegiance to a single large group could be created. The researchers created some superordinate goals that disrupted the small group boundaries and forced all the boys to work together in a single large group. For example, a truck carrying food for an overnight hike stalled in a ditch and could be rescued only by the cooperative efforts of all the boys; a highly desirable movie could be rented only by the pooled contributions of the entire camp; the water supply was cut off and could be restored only by the cooperative efforts of all campers.