The Theory and Practice of Group Psychotherapy


By Irvin D. Yalom

By Molyn Leszcz

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The classic work on group psychotherapy.
The Theory and Practice of Group Psychotherapy has been the standard text in the field for decades. In this completely updated sixth edition, Dr. Yalom and Dr. Leszcz draw on a decade of new research as well as their broad clinical wisdom and expertise. Each chapter is revised, reflecting the most recent developments in the field. There are new sections throughout, including online group therapy, modern analytic and relational approaches, interpersonal neurobiology, measurement-based care, culture and diversity, psychological trauma, and group therapy tailored for a range of clinical populations. At once scholarly and lively, this is the most up-to-date, incisive, and comprehensive text available on the practice of group psychotherapy.


Preface to the Sixth Edition

FIFTEEN YEARS HAVE PASSED SINCE THE FIFTH EDITION OF this textbook was published. Our task in this sixth edition is to describe the new and significant innovations in group therapy that have emerged during these years. We are pleased and grateful to continue our long collaboration, which began forty years ago at Stanford University. We have approached our work together as seasoned co-therapists and in writing this edition have sought to support and challenge one another. We write largely as “we,” with an interweaving of both voices. At certain points, to identify an experience personal to one of us, we switch to first person and include a parenthetical abbreviation to indicate which of us is taking over the narration (IY or ML).

Our aim is to provide our readers with a synthesis of new knowledge and accrued wisdom in the practice of group therapy. We make extensive use of clinical illustrations to bring these concepts and principles to life and make the book both practical and instructive. Like previous editions, this one is intended for students, trainees, and frontline practitioners as well as supervisors and teachers.

Since group therapy was first introduced in the 1940s, it has continued to adapt to reflect changes in clinical practice. As new clinical syndromes, settings, and theoretical approaches have emerged, so have corresponding variants of group therapy. The multiplicity of forms is so evident today that it makes more sense to speak of “group therapies” than of “group therapy.” The evidence is consistently strong, across all ages and clinical needs, that group therapy is effective, generally with outcomes equivalent to those of individual therapy, and far less costly. This is true both for mental health and for substance use disorder treatment as well as for the medically ill.

The Internet makes group therapy far more accessible today than it was in the predigital world. Geography is no longer the barrier to therapy that it once was. New technological platforms create new opportunities and challenges for group therapists: What is the same and what is different as group therapy moves from the group room to the group screen? These are questions we will address in this volume in a new chapter focused on online psychotherapy groups (see Chapter 14).

Now, as clients from diverse ethnocultural backgrounds access group therapy, whether in North America or elsewhere, it is important for therapists to develop a multicultural orientation as well as sensitivity and expertise in cultural adaptation. Therapy groups have always been settings for “difficult dialogues” and discourse; race and gender identity issues can be effectively addressed in a responsive therapy group environment (see Chapter 16). Group therapy is a powerful vehicle for working with traumatized and displaced individuals.

Paradoxically, however, professional training for group therapists has failed to keep pace with the widespread clinical application of the group therapies. Fewer and fewer training programs—whether in psychology, social work, counseling, or psychiatry—provide the depth of training and supervision that future practitioners require. All too often and in too many settings, therapists are thrust into action—and asked to lead groups of clients with complex histories and diverse needs—with little training or supervision in group therapy. Economic pressures, professional turf wars, and the current dominance of biological explanations and pharmacotherapy in mental health have all contributed to this situation. Each generation believes naively that it has discovered the true solution. Mental health is a field uniquely subject to an oscillation between zealous overvaluation and zealous devaluation, even by its own practitioners. We are therefore heartened that the American Psychological Association has recently recognized group psychotherapy as a designated specialty. This decision will encourage greater investment in education and training, and we hope it elevates group therapy to the status that its ever-widening practice warrants. We know that training can be transformative.

Today’s group therapists are influenced by the demand for greater accountability in practice. Evidence-based practice is a standard to which we must all adhere. For many years, practitioners resisted this emphasis on using research, measurement, and data as guides to effective practice as an intrusion into their work—one that impinged upon their autonomy and thwarted creativity. But it is anachronistic to think of evidence-based practice as narrowly prescriptive. We believe that a more effective approach is to embrace evidence-based practice as a set of guidelines and principles that enhance clinical effectiveness. Throughout the text we elaborate on the hallmarks of the evidence-based group therapist: building cohesive groups and strong relationships, effectively communicating genuine and accurate empathy, managing countertransference, and maintaining cultural awareness and sensitivity. Being reflective about our approach to our work and making our continued professional development a deliberate focus of attention are aspects of being an evidence-based group therapist. Data collection from our ongoing groups provides us with timely and relevant feedback about what is actually happening session to session, client by client (see Chapter 13).

We recognize that group therapists are now using a bewilderingly diverse set of approaches in their work. Cognitive-behavioral, psychoeducational, interpersonal, gestalt, supportive-expressive, modern analytic, psychoanalytic, dynamic-interactional, psychodrama—all of these, and many more, are used in group therapy today. Group therapists are also bringing advances in our understanding of human attachment and the neurobiology of interpersonal relationships to bear in group therapy in an effort to integrate mind, body, and brain into their work (see Chapters 2 and 3).

Although addressing all these group therapies in a single book presented challenges, we believe that the strategy guiding the first edition was still sound. That strategy was to separate “front” from “core” in discussions of each of the group therapies. The front consists of the trappings, the form, the techniques, the specialized language, and the aura surrounding any given ideological school; the core means those aspects of the experience that are intrinsic to the therapeutic process—that is, the bare-boned mechanisms of change.

If you disregard the “front” and consider only the actual mechanisms of effecting change in a client, you will find that the change mechanisms are limited in number and remarkably similar across groups. Therapy groups with similar goals that appear to be profoundly different if judged only by their external forms may rely on identical mechanisms of change. These mechanisms continue to constitute the central organizing principle of this book. We begin with a detailed discussion of eleven therapeutic factors and then describe a group psychotherapeutic approach based on them (see Chapters 1, 2, 3, and 4).

Deciding which types of groups to discuss presented another dilemma. The array of group therapies is now so vast that it is impossible to address each type of group separately. Instead, we center our discussion on a prototypical situation—the outpatient psychotherapy group—and then offer a set of principles that will enable the therapist to modify this fundamental group model to fit any specialized clinical situation (see Chapter 15).

Our prototypical outpatient psychotherapy group meets for at least several months with the ambitious goals of both symptomatic relief and personality change. We describe this group in detail from conception to conclusion, beginning with the principles of effective selection, group composition, and preparation (see Chapters 8 and 9), and then moving on to group development, from the first sessions to the advanced stages of the group, and common clinical challenges (see Chapters 10, 11, and 12).

Why focus on this particular form of group therapy when the contemporary therapy scene, driven by economic factors, is dominated by other types of groups meeting for briefer periods with more limited goals? The answer is that longer-term group therapy has been around for many decades, and practitioners have accumulated a vast body of knowledge from both empirical research and thoughtful clinical observation. We believe that the prototypical group we describe in this book is an intensive, ambitious form of therapy that demands much from both client and therapist. This group also affords therapists a unique lens through which to learn about group process, group dynamics, and group leadership that will serve them well in all their clinical work. The therapeutic strategies and techniques required to lead such a group are sophisticated and complex (see Chapters 5, 6, and 7). However, once students master them and understand how to modify them to fit specialized therapy situations, they will be in a position to fashion a group therapy that will be effective for a variety of clinical populations in different settings.

Trainees should aspire to be creative and compassionate therapists who understand how to put theory into practice. That requires, in turn, compassionate supervisors with similar understanding (see Chapter 16). The mounting demand for clinical care, and the effectiveness and efficiency of group therapy, make it the treatment modality of the future. Group therapists must be as prepared as possible for this opportunity. And they need to be able to care well for themselves, too, so that they can continue to treat others effectively and find meaning in their work.

Because most readers of this book will be clinicians, this text is intended to have immediate clinical relevance. We also believe, however, that it is imperative for clinicians to remain conversant with the world of research. Even if therapists do not personally engage in research, they must know how to evaluate the research of others.

One of the most important underlying assumptions in this text is that interpersonal interaction within the here-and-now is crucial to effective group therapy. The truly potent therapy group provides an arena in which clients can interact freely with others and then help members identify and understand what goes wrong in their interactions. Ultimately, it enables our clients to change those maladaptive patterns. We believe that groups based solely on other assumptions, such as psychoeducational or cognitive-behavioral principles, fail to reap the full therapeutic harvest. Each of these forms of group therapy can be made more effective by incorporating an awareness of interpersonal process. In this text we discuss, in depth, the extent and nature of the interactional focus and its ability to bring about significant character and interpersonal change. The interactional focus is the engine of group therapy, and therapists who are able to harness it are much better equipped to do all forms of group therapy, even if the group model does not emphasize or acknowledge the centrality of interaction (see Chapter 15).

My (IY) novel The Schopenhauer Cure may serve as a companion volume to this text. It is set in a therapy group and illustrates many of the principles of group process and therapist technique described here. Hence, at several points in this edition, we refer the reader to sections of The Schopenhauer Cure that offer fictionalized portrayals of therapist techniques.

Excessively overweight volumes tend to end up on the “reference book” shelves. To avoid that fate we have resisted substantially lengthening this text. The addition of much new material has thus required us to cut older sections and citations. This was a painful task, and the deletion of many condemned passages bruised our hearts as well as our fingers. But we hope the result is a timely and up-to-date work that will serve students and practitioners well for the next fifteen years and beyond.

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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:

1. Instillation of hope

2. Universality

3. Imparting information

4. Altruism

5. The corrective recapitulation of the primary family group

6. Development of socializing techniques

7. Imitative behavior

8. Interpersonal learning

9. Group cohesiveness

10. Catharsis

11. Existential 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.


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:

> Betty, a resistant eighty-six-year-old depressed woman, attended her first group. Nothing the group leaders provided in the form of preparation or encouragement matched the remarkable impact of an eighty-eight-year-old member, Sarah, who greeted the newcomer in the following way. “Welcome to the group, Betty. If you are anything like me this is the last place you thought you would ever come to and you are probably here only because your daughter forced you to come. But let me tell you something. This is a special, special place. Coming here has changed my life. I am just about ready to graduate but I am taking away with me so much—I am leaving with a small bag of jewels that will help me in my life outside of this program. I have learned how bad it is to be lonely, I learned how to ask for help and reach out to people, and I learned that I deserve people’s care and attention. Trust me; this will happen for you as well if you come and participate here.” <<

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


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


  • "The authors of the 6th edition of The Theory and Practice of Group Psychotherapy do an excellent job of presenting the art and science of leading psychotherapy groups. The material is suitable for mental health professionals across disciplines who want to build their knowledge and expertise for leading psychotherapy groups. This is an essential resource for learning and enhancing group leadership skills for all types of groups."—Nina W. Brown, professor and eminent scholar, Old Dominion University
  • "Once again, Yalom and Leszcz have hit it out of the park. The breadth and depth of the research covered is truly impressive. However, it's the remarkably engaging writing style that seamlessly weaves these empirically informed group psychotherapy principles within an interpersonal framework that makes this book a one-of-a-kind classic. The instructive and compelling clinical examples support beginning therapists, while the contemporary group interventions invites the experienced group leader into new territory."—Gary Burlingame, professor and chair of psychology, Brigham Young University
  • "Reading this eagerly awaited 6th edition of what is truly a classic in the field is like returning home after a time away: the comforting feeling of revisiting familiar tried-and-true notions intermingled with the excitement of new discoveries and developments in the field. This volume, like its predecessors, speaks so clearly to the group therapist, novice, and expert alike, in experience-near, clinician-friendly language, making the group experience come alive in the mind. It represents the state of the art of group therapy today."—Les R. Greene, distinguished life fellow, American Group Psychotherapy Association
  • "This new edition affords us the treasured opportunity to benefit from the wisdom and expertise of the phenomenal partnership of Irv Yalom and Molyn Leszcz. This work retains the strengths of past editions in terms of invaluable clinical insights and case examples, but introduces new material that enhances this edition. In response to the challenges posed by the COVID-19 pandemic, they have included a chapter on online groups. I look forward to sharing this updated edition and valued resource that is informed by recent research findings with my students and colleagues!"—Alexis D. Abernethy, professor of psychology, Fuller Seminary
  • "The partnership between Yalom and Leszcz brings new originality to a text that—like no other—has already shaped the field that it helped to spawn fifty years ago. Grounded in current scholarship, their further development of the interpersonal model—wide-ranging and comprehensive—gives this book renewed standing for therapists of all orientations-a lasting treasure for practitioners and teachers alike."—John Schlapobersky, author of from The Couch to The Circle: Group-Analytic Psychotherapy in Practice
  • "This book is a real classic. In view of an increasing acceptance of group psychotherapy within health systems of different countries, this recent edition is a truly essential help for clinicians and excellently bridges research results and clinical wisdom. It updates theory and practice issues of groups that meanwhile have supported generations of group psychotherapists."—Bernhard Strauss, University of Jena, Germany

On Sale
Dec 1, 2020
Page Count
832 pages
Basic Books

Irvin D. Yalom

About the Author

Irvin D. Yalom, MD, is professor emeritus of psychiatry at the Stanford University School of Medicine. He was the recipient of the 1974 Edward Strecker Award and the 1979 Foundations’ Fund Prize in Psychiatry. He is the author of When Nietzsche Wept (winner of the 1993 Commonwealth Club gold medal for fiction); Love’s Executioner, a memoir; Becoming Myself, a group therapy novel; The Schopenhauer Cure; and the classic textbooks Inpatient Group Psychotherapy and Existential Psychotherapy, among many other books. He lives in Palo Alto, California.

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Molyn Leszcz

About the Author

Molyn Leszcz, MD, FRCPC, CGP, DFAGPA, is professor of psychiatry at the University of Toronto. He is an award-winning clinical educator. Dr. Leszcz is the president of the American Group Psychotherapy Association (AGPA) and a distinguished fellow of the American Group Psychotherapy Association. He is the coauthor of Psychotherapy Essentials to Go: Achieving Psychotherapy Effectiveness. He lives in Toronto, Canada.

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