The Theory and Practice of Group Psychotherapy

Our task in this new edition was to incorporate the many new changes in the field and to jettison outmoded ideas and methods. But we had a dilemma: What if some of the changes in the field do not represent advances but, instead, retrogression? What if marketplace considerations demanding quicker, cheaper, more efficient methods act against the best interests of the client? And what if "efficiency" is but a euphemism for shedding clients from the fiscal rolls as quickly as possible? And what if these diverse market factors force therapists to offer less than they are capable of offering their clients?

If these suppositions are true, then the requirements of this revision become far more complex because we have a dual task: not only to present current methods and prepare student therapists for the contemporary workplace, but also to preserve the accumulated wisdom and techniques of our field even if some young therapists will not have immediate opportunities to apply them.

Since group therapy was first introduced in the 1940s, it has undergone a series of adaptations to meet the changing face of 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." Groups for panic disorder, groups for acute and chronic depression, groups to prevent depression relapse, groups for eating disorders, medical support groups for patients with cancer, HIV/AIDS, rheumatoid arthritis, multiple sclerosis, irritable bowel syndrome, obesity, myocardial infarction, paraplegia, diabetic blindness, renal failure, bone marrow transplant, Parkinson's, groups for healthy men and women who carry genetic mutations that predispose them to develop cancer, groups for victims of sexual abuse, for the confused elderly and for their caregivers, for clients with obsessive-compulsive disorder, first-episode schizophrenia, for chronic schizophrenia, for adult children of alcoholics, for parents of sexually abused children, for male batterers, for self-mutilators, for the divorced, for the bereaved, for disturbed families, for married couples—all of these, and many more, are forms of group therapy.

The clinical settings of group therapy are also diverse: a rapid turnover group for chronically or acutely psychotic patients on a stark hospital ward is group therapy, and so are groups for imprisoned sex offenders, groups for residents of a shelter for battered women, and open-ended groups of relatively well functioning individuals with neurotic or personality disorders meeting in the well-appointed private office of a psychotherapist.

And the technical approaches are bewilderingly different: cognitive-behavioral, psychoeducational, interpersonal, gestalt, supportive-expressive, psychoanalytic, dynamic-interactional, psychodrama—all of these, and many more, are used in group therapy.

This family gathering of group therapies is swollen even more by the presence of distant cousins to therapy groups entering the room: experiential classroom training groups (or process groups) and the numerous self-help (or mutual support) groups like Alcoholics Anonymous and other twelve-step recovery groups, Adult Survivors of Incest, Sex Addicts Anonymous, Parents of Murdered Children, Overeaters Anonymous, and Recovery, Inc. Although these groups are not formal therapy groups, they are very often therapeutic and straddle the blurred borders between personal growth, support, education, and therapy (see chapter 16 for a detailed discussion of this topic). And we must also consider the youngest, most rambunctious, and most unpredictable of the cousins: the Internet support groups, offered in a rainbow of flavors.

How, then, to write a single book that addresses all these group therapies? The strategy I chose thirty-five years ago when I wrote the first edition of this book seems sound to me still. My first step was to separate "front" from "core" in each of the group therapies. The front consists of the trappings, the form, the techniques, the specialized language, and the aura surrounding each of the ideological schools; the core consists of 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 the client, you will find that the change mechanisms are limited in number and are remarkably similar across groups. Therapy groups with similar goals that appear wildly different in external form may rely on identical mechanisms of change.

In the first two editions of this book, caught up in the positivistic zeitgeist surrounding the developing psychotherapies, I referred to these mechanisms of change as "curative factors." Educated and humbled by the passing years, I know now that the harvest of psychotherapy is not cure—surely, in our field, that is an illusion—but instead change or growth. Hence, yielding to the dictates of reality, I now refer to the mechanisms of change as "therapeutic factors" rather than "curative factors."

The therapeutic factors constitute the central organizing principle of this book. I begin with a detailed discussion of eleven therapeutic factors and then describe a psychotherapeutic approach that is based on them.

But which types of groups to discuss? The array of group therapies is now so vast that it is impossible for a text to address each type of group separately. How then to proceed? I have chosen in this book to center my discussion around a prototypic type of group therapy and then to offer a set of principles that will enable the therapist to modify this fundamental group model to fit any specialized clinical situation.

The prototypical model is the intensive, heterogeneously composed outpatient psychotherapy group, meeting for at least several months, with the ambitious goals of both symptomatic relief and personality change. Why focus on this particular form of group therapy when the contemporary therapy scene, driven by economic factors, is dominated by another type of group—a homogeneous, symptom-oriented group that meets for briefer periods and has more limited goals?

The answer is that long-term group therapy has been around for many decades and has accumulated a vast body of knowledge from both empirical research and thoughtful clinical observation. Earlier I alluded to contemporary therapists not often having the clinical opportunities to do their best work; I believe that the prototypical group we describe in this book is the setting in which therapists can offer maximum benefit to their clients. It is an intensive, ambitious form of therapy that demands much from both client and therapist. The therapeutic strategies and techniques required to lead such a group are sophisticated and complex. 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 any clinical population in any setting. Trainees should aspire to be creative and compassionate therapists with conceptual depth, not laborers with little vision and less morale. Managed care emphatically views group therapy as the treatment modality of the future. Group therapists must be as prepared as possible for this opportunity.

Because most readers of this book are clinicians, the text is intended to have immediate clinical relevance. I 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. Accordingly, the text relies heavily on relevant clinical, social, and psychological research.

While searching through library stacks during the writing of early editions of this book, I often found myself browsing in antiquated psychiatric texts. How unsettling it is to realize that the devotees of such therapy endeavors as hydrotherapy, rest cures, lobotomy, and insulin coma were obviously clinicians of high intelligence, dedication, and integrity. The same may be said of earlier generations of therapists who advocated venesection, starvation, purgation, and trephination. Their texts are as well written, their optimism as unbridled, and their reported results as impressive as those of contemporary practitioners.

Question: why have other health-care fields left treatment of psychological disturbance so far behind? Answer: because they have applied the principles of the scientific method. Without a rigorous research base, the psychotherapists of today who are enthusiastic about current treatments are tragically similar to the hydrotherapists and lobotomists of yesteryear. As long as we do not test basic principles and treatment outcomes with scientific rigor, our field remains at the mercy of passing fads and fashions. Therefore, whenever possible, the approach presented in this text is based on rigorous, relevant research, and attention is called to areas in which further research seems especially necessary and feasible. Some areas (for example, preparation for group therapy and the reasons for group dropouts) have been widely and competently studied, while other areas (for example, "working through" or countertransference) have only recently been touched by research. Naturally, this distribution of research emphasis is reflected in the text: some chapters may appear, to clinicians, to stress research too heavily, while other chapters may appear, to research-minded colleagues, to lack rigor.

Let us not expect more of psychotherapy research than it can deliver. Will the findings of psychotherapy research affect a rapid major change in therapy practice? Probably not. Why? "Resistance" is one reason. Complex systems of therapy with adherents who have spent many years in training and apprenticeship and cling stubbornly to tradition will change slowly and only in the face of very substantial evidence. Furthermore, front-line therapists faced with suffering clients obviously cannot wait for science. Also, keep in mind the economics of research. The marketplace controls the focus of research. When managed-care economics dictated a massive swing to brief, symptom-oriented therapy, reports from a multitude of well-funded research projects on brief therapy began to appear in the literature. At the same time, the bottom dropped out of funding sources for research on longer-term therapy, despite a strong clinical consensus about the importance of such research. In time we expect that this trend will be reversed and that more investigation of the effectiveness of psychotherapy in the real world of practice will be undertaken to supplement the knowledge accruing from randomized controlled trials of brief therapy. Another consideration is that, unlike in the physical sciences, many aspects of psychotherapy inherently defy quantification. Psychotherapy is both art and science; research findings may ultimately shape the broad contours of practice, but the human encounter at the center of therapy will always be a deeply subjective, nonquantifiable experience.

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 first provides an arena in which clients can interact freely with others, then helps them identify and understand what goes wrong in their interactions, and ultimately enables them 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 even more effective by incorporating an awareness of interpersonal process.

This point needs emphasis: It has great relevance for the future of clinical practice. The advent of managed care will ultimately result in increased use of therapy groups. But, in their quest for efficiency, brevity, and accountability, managed-care decision makers may make the mistake of decreeing that some distinct orientations (brief, cognitive-behavioral, symptom-focused) are more desirable because their approach encompasses a series of steps consistent with other efficient medical approaches: the setting of explicit, limited goals; the measuring of goal attainment at regular, frequent intervals; a highly specific treatment plan; and a replicable, uniform, manual-driven, highly structured therapy with a precise protocol for each session. But do not mistake the appearance of efficiency for true effectiveness.

In this text we discuss, in depth, the extent and nature of the interactional focus and its potency in bringing 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.

Initially I was not eager to undertake the considerable task of revising this text. The theoretical foundations and technical approach to group therapy described in the fourth edition remain sound and useful. But a book in an evolving field is bound to age sooner than later, and the last edition was losing some of its currency. Not only did it contain dated or anachronistic allusions, but also the field has changed. Managed care has settled in by now, DSM-IV has undergone a text revision (DSM-IV-TR), and a decade of clinical and research literature needed to be reviewed and assimilated into the text. Furthermore, new types of groups have sprung up and others have faded away. Cognitive-behavioral, psychoeducational, and problem-specific brief therapy groups are becoming more common, so in this revision we have made a special effort throughout to address the particular issues germane to these groups.

The first four chapters of this text discuss eleven therapeutic factors. Chapter 1 covers instillation of hope, universality, imparting information, altruism, the corrective recapitulation of the primary family group, the development of socializing techniques, and imitative behavior. Chapters 2 and 3 present the more complex and powerful factors of interpersonal learning and cohesiveness. Recent advances in our understanding of interpersonal theory and the therapeutic alliance that can strengthen therapist effectiveness have influenced our approach to these two chapters.

Chapter 4 discusses catharsis and existential factors and then attempts a synthesis by addressing the comparative importance and the interdependence of all eleven therapeutic factors.

The next two chapters address the work of the therapist. Chapter 5 discusses the tasks of the group therapist—especially those germane to shaping a therapeutic group culture and harnessing the group interaction for therapeutic benefit. Chapter 6 describes how the therapist must first activate the here-and-now (that is, plunge the group into its own experience) and then illuminate the meaning of the here-and-now experience. In this edition we deemphasize certain models that rely on the elucidation of group-as-a-whole dynamics (for example, the Tavistock approach)—models that have since proven ineffective in the therapy process. (Some omitted material that may still interest some readers will remain available at www.yalom.com.)

While chapters 5 and 6 address what the therapist must do, chapter 7 addresses how the therapist must be. It explicates the therapist's role and the therapist's use of self by focusing on two fundamental issues: transference and transparency. In previous editions, I felt compelled to encourage therapist restraint: Many therapists were still so influenced by the encounter group movement that they, too frequently and too extensively, "let it all hang out." Times have changed; more conservative forces have taken hold, and now we feel compelled to discourage therapists from practicing too defensively. Many contemporary therapists, threatened by the encroachment of the legal profession into the field (a result of the irresponsibility and misconduct of some therapists, coupled with a reckless and greedy malpractice industry), have grown too cautious and impersonal. Hence we give much attention to the use of the therapist's self in psychotherapy.

Chapters 8 through 14 present a chronological view of the therapy group and emphasize group phenomena and techniques that are relevant to each stage. Chapters 8 and 9, on client selection and group composition, include new research data on group therapy attendance, dropouts, and outcomes. Chapter 10, which describes the practical realities of beginning a group, includes a lengthy new section on brief group therapy, presents much new research on the preparation of the client for group therapy. The appendix contains a document to distribute to new members to help prepare them for their work in the therapy group.

Chapter 11 addresses the early stages of the therapy group and includes new material on dealing with the therapy dropout. Chapter 12 deals with phenomena encountered in the mature phase of the group therapy work: subgrouping, conflict, self-disclosure, and termination.

Chapter 13, on problem members in group therapy, adds new material to reflect advances in interpersonal theory. It discusses the contributions of intersubjectivity, attachment theory, and self psychology. Chapter 14 discusses specialized techniques of the therapist, including concurrent individual and group therapy (both combined and conjoint), co-therapy, leaderless meetings, dreams, videotaping, and structured exercises, the use of the written summary in group therapy, and the integration of group therapy and twelve-step programs.

Chapter 15, on specialized therapy groups, addresses the many new groups that have emerged to deal with specific clinical syndromes or clinical situations. It presents the critically important principles used to modify traditional group therapy technique in order to design a group to meet the needs of other specialized clinical situations and populations, and describes the adaptation of cognitive-behavioral and interpersonal therapy to groups. These principles are illustrated by in-depth discussions of various groups, such as the acute psychiatric inpatient group and groups for the medically ill (with a detailed illustration of a group for patients with cancer). Chapter 15 also discusses self-help groups and the youngest member of the group therapy family—the Internet support group.

Chapter 16, on the encounter group, presented the single greatest challenge for this revision. Because the encounter group qua encounter group has faded from contemporary culture, we considered omitting the chapter entirely. However, several factors argue against an early burial: the important role played by the encounter movement groups in developing research technology and the use of encounter groups (also known as process groups, T-groups (for "training"), or experiential training groups) in group psychotherapy education. Our compromise was to shorten the chapter considerably and to make the entire fourth edition chapter available at www.yalom.com for readers who are interested in the history and evolution of the encounter movement.

Chapter 17, on the training of group therapists, includes new approaches to the supervision process and on the use of process groups in the educational curriculum.

During the four years of preparing this revision I was also engaged in writing a novel, The Schopenhauer Cure, which 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 offered in this text. Hence, at several points in this fifth edition, I refer the reader to particular pages in The Schopenhauer Cure that offer fictionalized portrayals of therapist techniques.

Excessively overweight volumes tend to gravitate to the "reference book" shelves. To avoid that fate we have resisted lengthening this text. The addition of much new material has mandated the painful task of cutting older sections and citations. (I left my writing desk daily with fingers stained by the blood of many condemned passages.) To increase readability, we consigned almost all details and critiques of research method to footnotes or to notes at the end of the book. The review of the last ten years of group therapy literature has been exhaustive.