The Theory and Practice of Group Psychotherapy (17 page)

The drive to belong can create powerful feelings within groups. Members with a strong adherence to what is inside the group may experience strong pressure to exclude and devalue who and what is outside the bounds of the group.
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It is not uncommon for individuals to develop prejudice against groups to which they cannot belong. It is therefore not surprising that hostility often emerges against members of ethnic or racial groups to which entry for outsiders may be impossible. The implication for international conflict is apparent: intergroup hostility may dissolve in the face of some urgently felt worldwide crisis that only supranational cooperation can avert: atmospheric pollution or an international AIDS epidemic, for example. These principles also have implications for clinical work with small groups.

Intermember conflict during the course of group therapy must be contained. Above all, communication must not be ruptured, and the adversaries must continue to work together in a meaningful way, to take responsibility for their statements, and to be willing to go beyond namecalling. This is, of course, a major difference between therapy groups and social groups, in which conflicts often result in the permanent rupture of relationships. Clients’ descriptions of critical incidents in therapy (see chapter 2) often involve an episode in which they expressed strong negative affect. In each instance, however, the client was able to weather the storm and to continue relating (often in a more gratifying manner) to the other member.

Underlying these events is the condition of cohesiveness. The group and the members must mean enough to each other to be willing to bear the discomfort of working through a conflict. Cohesive groups are, in a sense, like families with much internecine warfare but a powerful sense of loyalty.

Several studies demonstrate that cohesiveness is positively correlated with risk taking and intensive interaction.
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Thus, cohesiveness is not synonymous with love or with a continuous stream of supportive, positive statements. Cohesive groups are groups that are able to embrace conflict and to derive constructive benefit from it. Obviously, in times of conflict, cohesiveness scales that emphasize warmth, comfort, and support will temporarily gyrate; thus, many researchers have reservations about viewing cohesiveness as a precise, stable, measurable, unidimensional variable and consider it instead as multidimensional.
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Once the group is able to deal constructively with conflict in the group, therapy is enhanced in many ways. I have already mentioned the importance of catharsis, of risk taking, of gradually exploring previously avoided or unknown parts of oneself and recognizing that the anticipated dreaded catastrophe is chimerical. Many clients are desperately afraid of anger—their own and that of others. A highly cohesive group encourages members to tolerate the pain and hurt that interpersonal learning may produce.

But keep in mind that it is the early engagement that makes such successful working-through later possible.
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The premature expression of excess hostility before group cohesion has been established is a leading cause of group fragmentation. It is important for clients to realize that their anger is not lethal. Both they and others can and do survive an expression of their impatience, irritability, and even outright rage. For some clients, it is also important to have the experience of weathering an attack. In the process, they may become better acquainted with the reasons for their position and learn to withstand pressure from others.
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Conflict may also enhance self-disclosure, as each opponent tends to reveal more and more to clarify his or her position. As members are able to go beyond the mere statement of position, as they begin to understand the other’s experiential world, past and present, and view the other’s position from their own frame of reference, they may begin to understand that the other’s point of view may be as appropriate for that person as their own is for themselves. The working through of extreme dislike or hatred of another person is an experience of great therapeutic power. A clinical illustration demonstrates many of these points (another example may be found in my novel
The Schopenhauer Cure
).
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• Susan, a forty-six-year-old, very proper school principal, and Jean, a twenty-one-year-old high school dropout, became locked into a vicious struggle. Susan despised Jean because of her libertine lifestyle, and what she imagined to be her sloth and promiscuity. Jean was enraged by Susan’s judgmentalism, her sanctimoniousness, her embittered spinsterhood, her closed posture to the world. Fortunately, both women were deeply committed members of the group. (Fortuitous circumstances played a part here. Jean had been a core member of the group for a year and then married and went abroad for three months. Just at that time Susan became a member and, during Jean’s absence, became heavily involved in the group.)

Both had had considerable past difficulty in tolerating and expressing anger. Over a four-month period, they interacted heavily, at times in pitched battles. For example, Susan erupted indignantly when she found out that Jean was obtaining food stamps illegally; and Jean, learning of Susan’s virginity, ventured the opinion that she was a curiosity, a museum piece, a mid-Victorian relic.

Much good group work was done because Jean and Susan, despite their conflict, never broke off communication. They learned a great deal about each other and eventually realized the cruelty of their mutual judgmentalism. Finally, they could both understand how much each meant for the other on both a personal and a symbolic level. Jean desperately wanted Susan’s approval; Susan deeply envied Jean for the freedom she had never permitted herself. In the working-through process, both fully experienced their rage; they encountered and then accepted previously unknown parts of themselves. Ultimately, they developed an empathic understanding and then an acceptance of each other. Neither could possibly have tolerated the extreme discomfort of the conflict were it not for the strong cohesion that, despite the pain, bound them to the group.

Not only are cohesive groups more able to express hostility among members but there is evidence that they are also more able to express hostility toward the leader.
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Regardless of the personal style or skill of group leaders, the therapy group will nonetheless come, often within the first dozen meetings, to experience some degree of hostility and resentment toward them. (See chapter 11 for a full discussion of this issue.) Leaders do not fulfill members’ fantasized expectations and, in the view of many members, do not care enough, do not direct enough, and do not offer immediate relief. If the group members suppress these feelings of disappointment or anger, several harmful consequences may ensue. They may attack a convenient scapegoat—another member or some institution like “psychiatry” or “doctors.” They may experience a smoldering irritation within themselves or within the group as a whole. They may, in short, begin to establish norms discouraging open expression of feelings. The presence of such scapegoating may be a signal that aggression is being displaced away from its more rightful source—often the therapist.
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Leaders who challenge rather than collude with group scapegoating not only safeguard against an unfair attack, they also demonstrate their commitment to authenticity and responsibility in relationships.

The group that is able to express negative feelings toward the therapist almost invariably is strengthened by the experience. It is an excellent exercise in direct communication and provides an important learning experience—namely, that one may express hostility directly without some ensuing irreparable calamity. It is far preferable that the therapist, the true object of the anger, be confronted than for the anger to be displaced onto some other member in the group. Furthermore, the therapist, let us pray, is far better able than a scapegoated member to withstand confrontation. The entire process is self-reinforcing; a concerted attack on the leader that is handled in a nondefensive, nonretaliatory fashion serves to increase cohesiveness still further.

One cautionary note about cohesion: misguided ideas about cohesion may interfere with the group task.
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Janis coined the term “groupthink” to describe the phenomenon of “deterioration of mental efficiency, reality testing, and moral judgment that results from group pressure.”
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Group pressure to conform and maintain consensus may create a groupthink environment. This is not an alliance-based cohesion that facilitates the growth of the group members; on the contrary, it is a misalliance based on naive or regressive assumptions about belonging. Critical and analytic thought by the group members needs to be endorsed and encouraged by the group leader as an essential group norm.
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Autocratic, closed and authoritarian leaders discourage such thought. Their groups are more prone to resist uncertainty, to be less reflective, and to close down exploration prematurely.
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Group Cohesiveness and Other Therapy-Relevant Variables

Research from both therapy and laboratory groups has demonstrated that group cohesiveness has a plethora of important consequences that have obvious relevance to the group therapeutic process.
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It has been shown, for example, that the members of a cohesive group, in contrast to the members of a noncohesive group, will:

1. Try harder to influence other group members
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2. Be more open to influence by the other members
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3. Be more willing to listen to others
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and more accepting of others
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4. Experience greater security and relief from tension in the group
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5. Participate more readily in meetings
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6. Self-disclose more
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7. Protect the group norms and exert more pressure on individuals deviating from the norms
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8. Be less susceptible to disruption as a group when a member terminates membership
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9. Experience greater ownership of the group therapy enterprise
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SUMMARY

By definition, cohesiveness refers to the attraction that members have for their group and for the other members. It is experienced at interpersonal, intrapersonal, and intragroup levels. The members of a cohesive group are accepting of one another, supportive, and inclined to form meaningful relationships in the group. Cohesiveness is a significant factor in successful group therapy outcome. In conditions of acceptance and understanding, members will be more inclined to express and explore themselves, to become aware of and integrate hitherto unacceptable aspects of self, and to relate more deeply to others. Self-esteem is greatly influenced by the client’s role in a cohesive group. The social behavior required for members to be esteemed by the group is socially adaptive to the individual out of the group.

In addition, highly cohesive groups are more stable groups, with better attendance and less turnover. Evidence was presented to indicate that this stability is vital to successful therapy: early termination precludes benefit for the involved client and impedes the progress of the rest of the group as well. Cohesiveness favors self-disclosure, risk taking, and the constructive expression of conflict in the group—phenomenon that facilitate successful therapy.

What we have yet to consider are the determinants of cohesiveness. What are the sources of high and low cohesiveness? What does the therapist do to facilitate the development of a highly cohesive group? These important issues will be discussed in the chapters dealing with the group therapist’s tasks and techniques.

Chapter 4

THE THERAPEUTIC FACTORS: AN INTEGRATION

W
e began our inquiry into the group therapy therapeutic factors with the rationale that the delineation of these factors would guide us to a formulation of effective tactics and strategies for the therapist. The compendium of therapeutic factors presented in chapter 1 is, I believe, comprehensive but is not yet in a form that has great clinical applicability. For the sake of clarity I have considered the factors as separate entities, whereas in fact they are intricately interdependent. In other words, I have taken the therapy process apart to examine it, and now it is time to put it back together again.

In this chapter I first consider how the therapeutic factors operate when they are viewed not separately but as part of a dynamic process. Next I address the comparative potency of the therapeutic factors. Obviously, they are not all of equal value. However, an absolute rank-ordering of therapeutic factors is not possible. Many contingencies must be considered. The importance of various therapeutic factors depends on the type of group therapy practiced. Groups differ in their clinical populations, therapeutic goals, and treatment settings—for example, eating disorders groups, panic disorder groups, substance abuse groups, medical illness groups, ongoing outpatient groups, brief therapy groups, inpatient groups, and partial hospitalization groups. They may emphasize different clusters of therapeutic factors, and some therapeutic factors are important at one stage of a group, whereas others predominate at another. Even within the same group, different clients benefit from different therapeutic factors. Like diners at a cafeteria, group members will choose their personalized menu of therapeutic factors, depending on such factors as their needs, their social skills, and their character structure.