The Theory and Practice of Group Psychotherapy (19 page)

After the Q-sort, which took thirty to forty-five minutes, each subject was interviewed for an hour by the three investigators. Their reasons for their choice of the most and least helpful items were reviewed, and a series of other areas relevant to therapeutic factors was discussed (for example, other, nonprofessional therapeutic influences in the clients’ lives, critical events in therapy, goal changes, timing of improvement, therapeutic factors in their own words).

Results

A sixty-item, seven-pile Q-sort for twenty subjects makes for complex data. Perhaps the clearest way to consider the results is a simple rank-ordering of the sixty items (arrived at by ranking the sum of the twenty pile placements for each item). Turn again to
table 4.1
. The number after each item represents its rank order. Thus, on average, item 48
(Discovering and accepting previously unknown or unacceptable parts of myself)
was considered the most important therapeutic factor by the subjects, item 38
(Adopting mannerisms or the style of another group member)
the least important, and so on.

The ten items the subjects deemed most helpful were, in order of importance:

1. Discovering and accepting previously unknown or unacceptable parts of myself.

2. Being able to say what was bothering me instead of holding it in.

3. Other members honestly telling me what they think of me.

4. Learning how to express my feelings.

5. The group’s teaching me about the type of impression I make on others.

6. Expressing negative and/or positive feelings toward another member.

7. Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others.

8. Learning how I come across to others.

9. Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same.

10. Feeling more trustful of groups and of other people.

Note that seven of the first eight items represent some form of catharsis or of insight. I again use
insight
in the broadest sense; the items, for the most part, reflect the first level of insight (gaining an objective perspective of one’s interpersonal behavior) described in chapter 2. This remarkable finding lends considerable weight to the principle, also described in chapter 2, that therapy is a dual process consisting of emotional experience and of reflection on that experience. More, much more, about this later.

The administration and scoring of a sixty-item Q-sort is so laborious that most researchers have since used an abbreviated version—generally, one that asks a subject to rank the twelve therapeutic factor categories rather than sixty individual items. However, four studies that replicate the sixty-item Q-sort study report remarkably similar findings.
¹⁵

If we analyze the twelve general categories,
^g
we find the following rank order of importance:

1. Interpersonal input

2. Catharsis

3. Cohesiveness

4. Self-understanding

5. Interpersonal output

6. Existential factors

7. Universality

8. Instillation of hope

9. Altruism

10. Family reenactment

11. Guidance

12. Identification
^h

A number of other replicating studies describe the therapeutic factors selected by group therapy outpatients.
¹⁶
These studies are in considerable agreement: the most commonly chosen therapeutic factors are catharsis, self-understanding, and interpersonal input, closely followed by cohesiveness and universality. The same trio of most helpful therapeutic factors (interpersonal input, self-understanding, and catharsis) has been reported in studies of personal growth groups.
¹⁷
One researcher suggests that the therapeutic factors fall into three main clusters: the remoralization factor (cluster of hope, universality, and acceptance), the self-revelation factor (self-disclosure and catharsis), and the specific psychological work factor (interpersonal learning and self-understanding).
¹⁸
This clustering resembles a factor analysis
ⁱ
of therapeutic factors collected from studies of American Group Psychotherapy Association Institute experiential groups suggesting that the group therapeutic factors fall into three main categories: early factors of belonging and remoralization common to all therapy groups; factors of guidance and instruction; and specific skill development factors. Despite different terminology, both of these clustering approaches suggest that the group therapeutic factors consist of universal mechanisms, mediating mechanisms, and specific change mechanisms.
¹⁹

Which therapeutic factors are least valued? All of the studies of therapy groups and personal growth groups report the same results: family reenactment, guidance, and identification. These results all suggest that the defining core of the therapeutic process in these therapy groups is an affectively charged, self-reflective interpersonal interaction, in a supportive and trusting setting.
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Comparisons of individual and group therapy therapeutic factors consistently underscore this finding
²¹
and support the importance of the basic concepts I discussed in chapter 2—the importance of the corrective emotional experience and the concept that the therapeutic here-and-now focus consists of an experiencing and a cognitive component.

In the following sections, I will incorporate these research findings in a broader discussion of the questions posed at the beginning of this chapter on the interrelationships and comparative potency of the therapeutic factors. Keep in mind throughout that these findings pertain to a specific type of therapy group: an interactionally based group with the ambitious goals of symptom relief and behavioral and characterological change. Later in this chapter I will present some evidence that other groups with different goals and shorter duration may capitalize on different clusters of therapeutic factors.

Catharsis

Catharsis has always assumed an important role in the therapeutic process, though the rationale behind its use has undergone a metamorphosis. For centuries, sufferers have been purged to be cleansed of excessive bile, evil spirits, and infectious toxins (the word itself is derived from the Greek “to clean”). Since Breuer and Freud’s 1895 treatise on the treatment of hysteria,
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many therapists have attempted to help clients rid themselves of suppressed, choked affect. What Freud and subsequently all dynamic psychotherapists have learned is that
catharsis is not enough
. After all, we have emotional discharges, sometimes very intense ones, all our lives without their leading to change.

The data support this conclusion. Although studies of clients’ appraisals of the therapeutic factors reveals the importance of catharsis, the research also suggests important qualifications. The Lieberman, Yalom, and Miles study starkly illustrates the limitations of catharsis per se.
²³
The authors asked 210 members of a thirty-hour encounter group to describe the most significant incident that occurred in the course of the group. Experiencing and expressing feelings (both positive and negative) was cited frequently.
Yet this critical incident was not related to positive outcome:
incidents of catharsis were as likely to be selected by members with poor outcomes as by those with good outcomes. Catharsis was not unrelated to outcome;
it was necessary but in itself not sufficient
. Indeed, members who cited only catharsis were somewhat more likely to have had a negative experience in the group. The high learners characteristically showed a profile of catharsis
plus some form of cognitive learning
. The ability to reflect on one’s emotional experience is an essential component of the change process.†

In the Q-sort therapeutic factor studies, the two items that are ranked most highly and are most characteristic of the catharsis category in factor analytic studies are items 34
(Learning how to express my feelings)
and 35
(Being able to say what was bothering me)
. Both of these items convey something other than the sheer act of ventilation or abreaction. They connote a sense of liberation and acquiring skills for the future. The other frequently chosen catharsis item—item 32
(Expressing negative and/or positive feelings toward another member)—
indicates the role of catharsis in the ongoing interpersonal process. Item 31, which most conveys the purest sense of sheer ventilation
(Getting things off my chest)
, was not highly ranked by group members.
²⁴

Interviews with the clients to investigate the reasons for their selection of items confirmed this view. Catharsis was viewed as
part of an interpersonal process;
no one ever obtains enduring benefit from ventilating feelings in an empty closet. Furthermore, as I discussed in chapter 3, catharsis is intricately related to cohesiveness. Catharsis is more helpful once supportive group bonds have formed; in other words, catharsis is more valued late rather than early in the course of the group.
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Conversely, strong expression of emotion enhances the development of cohesiveness: members who express strong feelings toward one another and work honestly with these feelings will develop close mutual bonds. In groups of clients dealing with loss, researchers found that expression of positive affect was associated with positive outcomes. The expression of negative affect, on the other hand, was therapeutic only when it occurred in the context of genuine attempts to understand oneself or other group members.
²⁶

Emotional expression is directly linked with hope and a sense of personal effectiveness. Emotional disclosure is also linked to the ability to cope: articulation of one’s needs permits oneself and the people in one’s environment to respond productively to life’s challenges. Women with early breast cancer who are emotionally expressive achieve a much better quality of life than those who avoid and suppress their distress.
²⁷
Recently bereaved HIV-positive men who are able to express emotions, grieve, and find meaning in their losses, maintain significantly higher immune function and live longer than those who minimize their distress and avoid the mourning process.
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In summary, then, the open expression of affect is vital to the group therapeutic process; in its absence, a group would degenerate into a sterile academic exercise. Yet it is only part of the process and must be complemented by other factors. One last point: the intensity of emotional expression is highly relative and must be appreciated not from the leader’s perspective but from that of each member’s experiential world. A seemingly muted expression of emotion may, for a highly constricted individual, represent an event of considerable intensity. On many occasions I have heard students view a videotape of a group meeting and describe the session as muted and boring, whereas the members themselves experienced the session as intense and highly charged.

Self-Understanding

The therapeutic factor Q-sort also underscores the important role that the intellectual component plays in the therapeutic process. Of the twelve categories, the two pertaining to the intellectual task in therapy (interpersonal input and self-understanding) are both ranked highly.
Interpersonal input,
discussed at some length in chapter 2, refers to the individual’s learning how he or she is perceived by other people. It is the crucial first step in the therapeutic sequence of the therapeutic factor of interpersonal learning.

The category of
self-understanding
is more problematic. It was constructed to permit investigation of the importance of derepression and of the intellectual understanding of the relationship between past and present (genetic insight). Refer back to
table 4.1
and examine the five items of the “self-understanding” category. It is clear that the category is an inconsistent one, containing several very different elements. There is poor correlation among items, some being highly valued by group therapy members and some less so. Item 48,
Discovering and accepting previously unknown or unacceptable parts of myself,
is the
single most valued item
of all the sixty. Two items (46 and 47) that refer to understanding causes of problems and to recognizing the existence of interpersonal distortion are also highly valued. The item that most explicitly refers to genetic insight, item 50, is considered of little value by group therapy clients.

This finding has been corroborated by other researchers. One study replicated the therapeutic factor Q-sort study and, on the basis of a factor analysis, subdivided insight into two categories: self-understanding and genetic insight. The sample of seventy-two group therapy members ranked self-understanding fourth of fourteen factors and genetic insight eighth.
²⁹
Another study concluded that genetic interpretations were significantly less effective than here-and-now feedback in producing positive group therapy outcomes. In fact, clients not only showed little benefit from genetic interpretations but in particular considered the leaders’ efforts in this regard unproductive. Comembers were more effective: their efforts at linking present to past contained less jargon and were linked more directly to actual experience than were the therapists’ more conceptual, less “real” explanations.
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