The Theory and Practice of Group Psychotherapy

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The Therapeutic Factors

DOES GROUP THERAPY HELP CLIENTS? INDEED, IT DOES. A persuasive body of outcome research has demonstrated consistently and unequivocally that group therapy is a highly effective form of psychotherapy. Not only is it at least equal to individual psychotherapy in its power to provide benefit, it also makes more efficient use of mental health care resources.¹ Yet, paradoxically, mental health professional training programs have reduced training in group therapy. This is a matter of great concern: we need to ensure high levels of quality in group therapies if we are to achieve the impact that we desire—and that our clients require.² Throughout this text we will focus on the group factors and the characteristics of leaders that contribute to therapeutic effectiveness.

How does group therapy help clients? A naive question, perhaps. But if we can answer it with some measure of precision and certainty, we will have at our disposal a central organizing principle with which to approach the most vexing and controversial problems of psychotherapy. Once identified, the crucial aspects of the process of change will constitute a rational basis for the therapist’s selection of tactics and strategies to shape the group experience, maximizing its potency with different clients and in different settings. Though group therapy works, there is also great variability in the effectiveness of therapists.³ Understanding how best to implement these therapeutic processes is at the heart of effective group therapy work. Fortunately, there is much to guide us from the research evidence. Experience alone does not confer greater effectiveness. What does? Deliberate practice, self-reflection, feedback on one’s practice, and the wise use of an empathic and attuned therapeutic relationship.⁴

We suggest that therapeutic change is an enormously complex process that occurs through an intricate interplay of human experiences, which we will refer to as “therapeutic factors.” There is considerable advantage in approaching the complex through the simple, the total phenomenon through its basic component processes. Accordingly, we begin by describing and discussing these elemental factors.

From our perspective, natural lines of cleavage divide the therapeutic experience into eleven primary factors:

In the rest of this chapter, we discuss the first seven factors. Interpersonal learning and group cohesiveness are so important and complex that we address them separately in the next two chapters. Existential factors are discussed in Chapter 4, where they are best understood in the context of other material presented there. Catharsis is intricately interwoven with other therapeutic factors and will also be discussed in Chapter 4.

The distinctions among these factors can be arbitrary, and though we discuss them singly, they are interdependent and neither occur nor function separately. Moreover, these factors may represent different parts of the change process: some factors (for example, interpersonal learning) act at the level of cognition; others (for example, the development of socializing techniques) act at the level of behavioral change; still others (for example, catharsis) act at the level of emotion. Some (for example, cohesiveness) may be more accurately described as both a therapeutic force itself and a precondition for change. Although the same therapeutic factors operate in every type of therapy group, their interplay and differential importance can vary widely from group to group. Furthermore, because of individual differences, participants in the same group benefit from different therapeutic factors.⁵

Keeping in mind that the therapeutic factors are arbitrary constructs, we can nevertheless view them as providing a cognitive map for the student-reader.⁶ This grouping of the therapeutic factors is not set in concrete; other clinicians and researchers have arrived at different, and also arbitrary, clusters of factors. One team of researchers posited that there is a core therapeutic factor: clients feeling hopeful that their emotional expression and relational awareness will translate into social learning.⁷ No explanatory system can encompass all of therapy. At its core, the therapy process is infinitely complex, and there is no end to the number of pathways through the experience. (We will discuss all of these issues more fully in Chapter 4.)

The inventory of therapeutic factors we propose issues from our clinical experience, from the experience of other therapists, from the views of clients successfully treated in group therapy, and from relevant systematic research. None of these sources is beyond doubt, however; neither group members nor group leaders are entirely objective, and our research methodology is often limited in its scope.

From the group therapists we obtain a variegated and internally inconsistent inventory of therapeutic factors reflecting the study of a wide range of clients and groups. Therapists, by no means disinterested or unbiased observers, have each invested considerable time and energy into mastering a certain therapeutic approach. Their answers will be determined largely by their particular school of conviction—the allegiance effect.⁸ Even among therapists who share the same ideology and speak the same language, there may be no consensus about the reasons clients improve. But that does not surprise us. The history of psychotherapy abounds in healers who were effective, but not for the reasons they supposed. Who has not had a client who made vast improvement for entirely obscure reasons?

One important source of information comes from group members’ determination of the therapeutic factors they considered most and least helpful. Researchers continue to raise important questions about the study of therapeutic factors. Do the therapeutic factors impact all group members equally? What influences our clients’ responses? Perhaps the relationship to the therapist, or to the group? What about session quality or depth?⁹ Moreover, research has also shown that the therapeutic factors valued by group members may differ greatly from those cited by their therapists or by group observers.¹⁰ Member responses may also be affected by a whole host of other variables: the type of group (that is, whether outpatient, inpatient, day hospital, or brief therapy);¹¹ the client’s age and diagnosis;¹² the client’s motivational stage and attachment style;¹³ the ideology of the group leader;¹⁴ and the manner in which group members experience the same event in different ways and impact one another’s experiences.¹⁵

Despite these limitations, clients’ reports are a rich and relatively untapped source of information. After all, it is their experience that matters, and the further we move from their experiences, the more inferential our conclusions. To be sure, there are aspects of the process of change that operate outside a client’s awareness. But it does not follow that we should disregard what clients say. Paper-and-pencil or sorting questionnaires provide easy data but often miss the nuances and the richness of the client experience. There is an art to obtaining clients’ reports. The more the questioner can enter into the experiential world of the client, the more lucid and meaningful the report of the therapy experience becomes.

In addition to therapists’ views and clients’ reports, there is a third important method of evaluating therapeutic factors: systematic research. The most common research strategy by far is to correlate in-therapy variables with therapy outcomes. By discovering which variables are significantly related to successful outcomes, one can establish a reasonable basis from which to begin to delineate therapeutic factors. However, there are many inherent problems in this approach: the measurement of outcome is itself a methodological morass—and the selection and measurement of the in-therapy variables are equally problematic.¹⁶

We have drawn from all these methods to derive the therapeutic factors discussed in this book. Still, we do not consider these conclusions definitive; rather, we offer them as provisional guidelines that may be tested and deepened by others.

INSTILLATION OF HOPE

Research has consistently demonstrated that the instillation and maintenance of hope is crucial in any psychotherapy. Several studies have demonstrated that a client’s high expectation of help is significantly correlated with a positive therapy outcome.¹⁷ Consider the massive data documenting the efficacy of faith healing and placebo treatment—therapies mediated entirely through hope and conviction. In group therapy, the presence of hope deepens client engagement in the group’s work.¹⁸ A positive outcome in psychotherapy is more likely when the client and the therapist have similar and positive expectations of the treatment.¹⁹ The power of expectations extends beyond imagination alone: brain imaging studies demonstrate that the placebo is not inactive but can have a direct physiological effect on the brain.²⁰

Group therapists can capitalize on this factor by doing whatever they can to increase clients’ belief and confidence in the efficacy of the group mode. This task begins before the group starts, in the pregroup orientation. Here, the therapist reinforces positive expectations, corrects negative preconceptions, and presents a lucid and powerful explanation of the group’s healing properties tied specifically to an accessible and culturally resonant explanation of client difficulties (see Chapters 9 and 10 for a full discussion of pregroup procedures).

Group therapy not only draws from the general ameliorative effects of positive expectations but also benefits from a source of hope unique to the group format. Therapy groups invariably contain individuals who are at different points along a coping-collapse continuum. Each member thus has considerable contact with others—often individuals with similar problems—who have improved as a result of therapy. I have often heard clients remark at the end of their group therapy how important it was for them to have observed the improvement of others.

Group therapists should by no means be above exploiting this factor by periodically calling attention to the improvement that members have made. If we happen to receive notes from recently terminated members noting their continued improvement, we make a point of sharing them with the current group. Longer-term group members often assume this function by offering spontaneous testimonials to new, skeptical members.

A powerful example took place in a geriatric psychiatric day hospital:

Research has shown that it is also vitally important that therapists believe in themselves and in the efficacy of their group. It is essential to nurture and sustain a sense of one’s own therapeutic effectiveness (see Chapter 16 for more on therapist self-care).²¹ In initial meetings with clients, we share our conviction with them and attempt to imbue them with our optimism.

Many of the self-help groups—for example, Compassionate Friends (for bereaved parents), Men Overcoming Violence (men who batter), Survivors of Incest, Gilda’s Club (for cancer patients and their families), the Depression and Bipolar Support Alliance, and Mended Heart (heart surgery patients)—place heavy emphasis on the instillation of hope.²² In twelve-step recovery fellowships such as Alcoholics Anonymous, Narcotics Anonymous, and Overeaters Anonymous, most meetings begin with a member sharing their story of “experience, strength, and hope” with other members. In AA, successful members tell their stories of downfall and subsequent recovery with the help of the program over and over again, not only to instill hope in new members, but to remind themselves that life can continue to “get better” if they stay sober. One of the great strengths of the organization is the fact that it is run by members, not professionals; the speakers, meeting leaders, and other officers are all recovering alcoholics—living inspirations to the others.

In the same way, some substance abuse treatment programs mobilize hope in participants by employing recovering drug addicts to serve as peer group leaders. Many programs have been founded by and/or are staffed by recovering addicts who have become professional counselors and therapists. Members are inspired by them: their expectations are raised by contact with those who have trod the same path and found the way back. Self-management groups for individuals with chronic medical illnesses, such as arthritis or heart disease, also use trained peers to encourage members to cope actively with their medical conditions.²³ The inspiration provided to participants by their peers is a key part of the therapy process. These groups improve medical outcomes, reduce health-care costs, promote a sense of self-efficacy in participants, and often make group interventions more impactful than individual therapies.²⁴

UNIVERSALITY

Many individuals enter therapy with the disquieting thought that they are unique in their wretchedness, that they alone have certain frightening or unacceptable problems, thoughts, impulses, and fantasies. To some extent this is true for all of us, but many clients, because of their extreme social isolation, have a heightened sense of uniqueness. Their interpersonal difficulties preclude the possibility of deep intimacy. In everyday life they neither learn about others’ analogous feelings and experiences nor avail themselves of the opportunity to confide in, and ultimately to be validated and accepted by, others.

In the therapy group, especially in the early stages, the disconfirmation of a client’s feelings of uniqueness is a powerful source of relief. After hearing other members disclose concerns similar to their own, clients report feeling more allied with the world. They may describe the process as a “welcome to the human race” experience. Simply put, the phenomenon finds expression in the cliché “We’re all in the same boat”—or, perhaps more cynically, “Misery loves company.” For some clients, feeling human among other humans is the beginning of recovery and a central feature of the healing context that group therapists aim to create.²⁵