The Theory and Practice of Group Psychotherapy (24 page)

Group cohesiveness operates as a therapeutic factor at first by means of group support, acceptance, and the facilitation of attendance and later by means of the interrelation of group esteem and self-esteem and through its role in interpersonal learning. It is only after the development of group cohesiveness that members may engage deeply and constructively in the self-disclosure, confrontation, and conflict essential to the process of interpersonal learning. Therapists must appreciate this necessary developmental sequence to help prevent early group dropouts. In a study of therapeutic factors in long-term inpatient treatment in Germany, clinical improvement was related to the experience of early cohesion and belonging. Cohesion set the stage for greater personal self-disclosure, which generated the interpersonal feedback that produced behavioral and psychological change.
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An outpatient study demonstrated that the longer group members participated in the group, the more they valued cohesiveness, self-understanding, and interpersonal output.
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Students in eleven-session counseling groups valued universality more in the first half of the group and interpersonal learning in the second half.
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In a study of twenty-six-session growth groups, universality and hope declined in importance through the course of the group, whereas catharsis increased.
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In a study of spouse abusers, universality was the prominent factor in early stages, while the importance of group cohesion grew over time.
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This emphasis on universality may be characteristic in the treatment of clients who feel shame or stigma. The cohesion that promotes change, however, is best built on a respect and acceptance of personal differences that takes time to mature. In another study, psychiatric inpatients valued universality, hope, and acceptance most, but later, when they participated in outpatient group psychotherapy, they valued self-understanding more.
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In summary, the therapeutic factors clients deem most important vary with the stage of group development. The therapist’s attention to this finding is as important as the therapist’s congruence with the client on therapeutic factors reviewed in the preceding section. Clients’ needs and goals change during the course of therapy. In chapter 2, I described a common sequence in which group members first seek symptomatic relief and then, during the first months in therapy, formulate new goals, often interpersonal ones of relating more deeply to others, learning to love, and being honest with others. As members’ needs and goals shift during therapy, so, too, must the necessary therapeutic processes. Modern enlightened psychotherapy is often termed dynamic psychotherapy because it appreciates the dynamics, the motivational aspects of behavior, many of which are not in awareness. Dynamic therapy may be thought of also as changing, evolving psychotherapy: clients change, the group goes through a developmental sequence, and the therapeutic factors shift in primacy and influence during the course of therapy.

Therapeutic Factors Outside the Group

Although I suggest that major behavioral and attitudinal shifts require a degree of interpersonal learning, occasionally group members make major changes without making what would appear to be the appropriate investment in the therapeutic process. This brings up an important principle in therapy:
The therapist or the group does not have to do the entire job.
Personality reconstruction as a therapeutic goal is as unrealistic as it is presumptuous. Our clients have many adaptive coping strengths that may have served them well in the past, and a boost from some event in therapy may be sufficient to help a client begin coping in an adaptive manner. Earlier in this text I used the term “adaptive spiral” to refer to the process in which one change in a client begets changes in his or her interpersonal environment that beget further personal change. The adaptive spiral is the reverse of the vicious circle, in which so many clients find themselves ensnared—a sequence of events in which dysphoria has interpersonal manifestations that weaken or disrupt interpersonal bonds and consequently create further dysphoria.

These points are documented when we ask clients about other therapeutic influences or events in their lives that occurred concurrently with their therapy course. In one sample of twenty clients, eighteen described a variety of extragroup therapeutic factors. Most commonly cited was a new or an improved interpersonal relationship with one or more of a variety of figures (member of the opposite sex, parent, spouse, teacher, foster family, or new set of friends).
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Two clients claimed to have benefited by going through with a divorce that had long been pending. Many others cited success at work or school, which raised their self-esteem as they established a reservoir of real accomplishments. Others became involved in some new social venture (a YMCA group or community action group).

Perhaps these are fortuitous, independent factors that deserve credit, along with group therapy, for the successful outcome. In one sense that is true: the external event augments therapy. Yet it is also true that the potential external event had often always been there: the therapy group mobilized the members to take advantage of resources that
had long been available to them in their environment
.

Consider Bob, a lonely, shy, and insecure man, who attended a time-limited twenty-five-session group. Though he spent considerable time discussing his fear about approaching women, and though the group devoted much effort to helping him, there seemed little change in his outside behavior. But at the final meeting of the group, Bob arrived with a big smile and a going-away present for the group: a copy of a local newspaper in which he had placed an ad in the personals!

The newspapers, spouses, online sites, relatives, potential friends, social organizations, and academic or job opportunities are always out there, available, waiting for the client to seize them. The group may have given the client only the necessary slight boost to allow him or her to exploit these previously untapped resources. Frequently the group members and the therapist are unaware of the importance of these factors and view the client’s improvement with skepticism or puzzlement. And frequently the group may end with no evidence of their ultimate impact on the member. Later, when I discuss combined treatment, I will emphasize the point that therapists who continue to see clients in individual therapy long after the termination of the group often learn that members make use of the internalized group months, even years, later.

A study of encounter group members who had very successful outcomes yielded corroborative results.
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More often than not, successful members did not credit the group for their change. Instead, they described the beneficial effects of new relationships they had made, new social circles they had created, new recreational clubs they had joined, greater work satisfaction they had found. Closer inquiry indicated, of course, that the relationships, social circles, recreational clubs, and work satisfaction had not suddenly and miraculously materialized. They had long been available to the individual who was mobilized by the group experience to take advantage of these resources and exploit them for satisfaction and personal growth.

I have considered, at several places in this text, how the skills group members acquire prepare them for new social situations in the future. Not only are extrinsic skills acquired but intrinsic capacities are released. Psychotherapy removes neurotic obstructions that have stunted the development of the client’s own resources. The view of therapy as
obstruction removal
lightens the burden of therapists and enables them to retain respect for the rich, never fully knowable, capacities of their clients.

Individual Differences and Therapeutic Factors

The studies cited in this chapter report average values of therapeutic factors as ranked by groups of clients. However, there is considerable individual variation in the rankings, and some researchers have attempted to determine the individual characteristics that influence the selection of therapeutic factors. Although demographic variables such as sex and education make little difference, there is evidence that level of functioning is significantly related to the ranking of therapeutic factors, for example, higher-functioning individuals value interpersonal learning (the cluster of interpersonal input and output, catharsis, and self-understanding) more than do the lower-functioning members in the same group.
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It has also been shown that lower-functioning inpatient group members value the instillation of hope, whereas higher-functioning members in the same groups value universality, vicarious learning, and interpersonal learning.
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A large number of other studies demonstrate differences between individuals (high encounter group learners vs. low learners, dominant vs. nondominant clients, overly responsible vs. nonresponsible clients, high self acceptors vs. low self acceptors, highly affiliative vs. low affiliative students).
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Not everyone needs the same things or responds in the same way to group therapy. There are many therapeutic pathways through the group therapy experience. Consider, for example, catharsis. Some restricted individuals benefit by experiencing and expressing strong affect, whereas others who have problems of impulse control and great emotional liability may not benefit from catharsis but instead from reining in emotional expression and acquiring intellectual structure. Narcissistic individuals need to learn to share and to give, whereas passive, self-effacing individuals need to learn to express their needs and to become
more
selfish. Some clients may need to develop satisfactory, even rudimentary, social skills; others may need to work with more subtle issues—for example, a male client who needs to stop sexualizing all women and devaluing or competing with all men.

In summary, it is clear that the comparative potency of the therapeutic factors is a complex issue. Different factors are valued by different types of therapy groups, by the same group at different developmental stages, and by different clients within the same group, depending on individual needs and strengths. Overall, however, the preponderance of research evidence indicates that the power of the interactional outpatient group emanates from its interpersonal properties. Interpersonal interaction and exploration (encompassing catharsis and self-understanding) and group cohesiveness are the sine qua non of effective group therapy, and effective group therapists must direct their efforts toward maximal development of these therapeutic resources. The next chapters will consider the role and the techniques of the group therapist from the viewpoint of these therapeutic factors.

Chapter 5

THE THERAPIST: BASIC TASKS

N
ow that I have considered how people change in group therapy, it is time to turn to the therapist’s role in the therapeutic process. In this chapter, I consider the basic tasks of the therapist and the techniques by which they may be accomplished.

The four previous chapters contend that therapy is a complex process consisting of elemental factors that interlace in an intricate fashion. The group therapist’s job is to create the machinery of therapy, to set it in motion, and to keep it operating with maximum effectiveness. Sometimes I think of the therapy group as an enormous dynamo: often the therapist is deep in the interior—working, experiencing, interacting (and being personally influenced by the energy field); at other times, the therapist dons mechanic’s clothes and tinkers with the exterior, lubricating, tightening nuts and bolts, replacing parts.

Before turning to specific tasks and techniques, I wish to emphasize something to which I will return again and again in the following pages. Underlying all considerations of technique must be a consistent, positive relationship between therapist and client. The basic posture of the therapist to a client must be one of concern, acceptance, genuineness, empathy
. Nothing, no technical consideration, takes precedence over this attitude.
Of course, there will be times when the therapist challenges the client, shows frustration, even suggests that if the client is not going to work, he or she should consider leaving the group. But these efforts (which in the right circumstances may have therapeutic clout) are never effective unless they are experienced against a horizon of an accepting, concerned therapist-client relationship.

I will discuss the techniques of the therapist in respect to three fundamental tasks:

1. Creation and maintenance of the group

2. Building a group culture

3. Activation and illumination of the here-and-now

I discuss the first of these only briefly here and will pick it up in greater detail after I present the essential background material of chapters 8, 9, and 10. In this chapter, I focus primarily on the second task,
building a group culture,
and, in the next chapter turn to the third task, the
activation and illumination
of the
here-and-now.

CREATION AND MAINTENANCE OF THE GROUP

The group leader is solely responsible for creating and convening the group. Your offer of professional help serves as the group’s initial raison d’être, and you set the time and place for meetings. A considerable part of the maintenance task is performed before the first meeting, and, as I will elaborate in later chapters, the leader’s expertise in the selection and the preparation of members will greatly influence the group’s fate.