The Theory and Practice of Group Psychotherapy (23 page)

The group well demonstrates the double meaning of the word
apartness:
we are separate, lonely,
apart from
but also a
part of.
One of my members put it elegantly when she described herself as a lonely ship in the dark. Even though no physical mooring could be made, it was nonetheless enormously comforting to see the lights of other ships sailing the same water.

COMPARATIVE VALUE OF THE THERAPEUTIC FACTORS: DIFFERENCES BETWEEN CLIENTS’ AND THERAPISTS’ VIEWS

Do clients and therapists agree about what helps in group psychotherapy? Research comparing therapists’ and clients’ assessments is instructive. First, keep in mind that therapists’ published views of the range of therapeutic factors are broadly analogous to the factors I have described.
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But, of course, leaders from different ideological schools differ in their weighting of the therapeutic factors, even though they resemble one another in their therapeutic relationships.
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The research data tells us that therapists and clients differ in their valuation of the group therapeutic factors. A study of 100 acute inpatient group members and their thirty behaviorally oriented therapists showed that the therapists and clients differed significantly in their ranking of therapeutic factors. Therapists placed considerably more weight on client modeling and behavioral experimentation, whereas the group members valued other factors more: self-responsibility, self-understanding, and universality.
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Another study showed that groups of alcoholics ranked existential factors far higher than did their therapists.
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It should not be surprising that substance abuse clients value accountability and personal responsibility highly. These factors are cornerstones of twelve-step groups.

Fifteen HIV-positive men treated in time-limited cognitive-behavioral therapy groups for depression cited different therapeutic factors than their therapists. Members selected social support, cohesion, universality, altruism, and existential factors, whereas the therapists (in line with their ideological school) considered cognitive restructuring as the mutative agent.
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A large survey of prison therapy groups notes that inmates agree with their group leaders about the importance of interpersonal learning but value existential factors far more highly than their therapists do.
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As noted earlier, incest victims in group therapy value highly the therapeutic factor of family reenactment.
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Therapists are wise to be alert to these divergences. Client-therapist disagreement about the goals and tasks of therapy may impair the therapeutic alliance.† This issue is not restricted to group therapy. Client-therapist discrepancies on therapeutic factors also occur in individual psychotherapy. A large study of psychoanalytically oriented therapy found that clients attributed their successful therapy to relationship factors, whereas their therapists gave precedence to technical skills and techniques.
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In general, analytic therapists value the coming to consciousness of unconscious factors and the subsequent linkage between childhood experiences and present symptoms far more than do their clients, who deny the importance or even the existence of these elements in therapy; instead they emphasize the personal elements of the relationship and the encounter with a new, accepting type of authority figure.

A turning point in the treatment of one client starkly illustrates the differences. In the midst of treatment, the client had an acute anxiety attack and was seen by the therapist in an emergency session. Both therapist and client regarded the incident as critical, but for very different reasons. To the therapist, the emergency session unlocked the client’s previously repressed memories of early incestuous sex play and facilitated a working-through of important Oedipal material. The client, on the other hand, entirely dismissed the
content
of the emergency session and instead valued the relationship implications: the caring and concern expressed by the therapist’s willingness to see him in the middle of the night.

A similar discrepancy between the client’s and the therapist’s view of therapy is to be found in
Every Day Gets a Little Closer,
a book I coauthored with a client.
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Throughout the treatment she and I wrote independent, impressionistic summaries of each meeting and handed them in, sealed, to my secretary. Every few months we read each other’s summaries and discovered that we valued very different aspects of the therapeutic process. All my elegant interpretations? She never even heard them! What she remembered and treasured were the soft, subtle, personal exchanges, which, to her, conveyed my interest and caring for her.

Reviews of process and outcome research reveal that clients’ ratings of therapist engagement and empathy are more predictive of therapeutic success than therapists’ ratings of these same variables.
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These findings compel us to pay close attention to the client’s view of the most salient therapeutic factors. In research as in clinical work, we do well to heed the adage:
Listen to the client.

To summarize: Therapists and their clients differ in their views about important therapeutic factors: clients consistently emphasize the importance of the relationship and the personal, human qualities of the therapist, whereas therapists attribute their success to their techniques. When the therapist-client discrepancy is too great, when therapists emphasize therapeutic factors that are incompatible with the needs and capacities of the group members, then the therapeutic enterprise will be derailed: clients will become bewildered and resistant, and therapists will become discouraged and exasperated. The therapist’s capacity to respond to client vulnerability with warmth and tenderness is pivotal and may lie at the heart of the transformative power of therapy.
†

THERAPEUTIC FACTORS: MODIFYING FORCES

It is not possible to construct an absolute hierarchy of therapeutic factors. There are many modifying forces: therapeutic factors are influenced by the type of group therapy, the stage of therapy, extragroup forces, and individual differences.

Therapeutic Factors in Different Group Therapies

Different types of group therapy favor the operation of different clusters of curative factors. Consider, for example, the therapy group on an acute inpatient ward. Members of inpatient therapy groups do not select the same constellation of three factors (interpersonal learning, catharsis, and self-understanding) as most members of outpatient groups.
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Rather, they select a wide range of therapeutic factors that reflect, I believe, both the heterogeneous composition of inpatient therapy groups and the cafeteria theory of improvement in group therapy. Clients who differ greatly from one another in ego strength, motivation, goals, and type and severity of psychopathology meet in the same inpatient group and, accordingly, select and value different aspects of the group procedure.

Many more inpatients than outpatients select the therapeutic factors of instillation of hope and existential factors (especially the assumption of responsibility). Instillation of hope looms large in inpatient groups because so many individuals enter the hospital in a state of utter demoralization. Until the individual acquires hope and the motivation to engage in treatment, no progress will be made. Often the most effective antidote to demoralization is the presence of others who have recently been in similar straits and discovered a way out of despair. Existential factors (defined on the research instruments generally as “assumption of ultimate responsibility for my own life”) are of particular importance to inpatients, because often hospitalization confronts them with the limits of other people; external resources have been exhausted; family, friends, therapists have failed; they have hit bottom and realize that, in the final analysis, they can rely only on themselves. (On one inpatient Q-sort study, the assumption of responsibility, item 60, was ranked first of the sixty items.)
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A vast range of homogeneously composed groups meet today. Let us review the therapeutic factors chosen by the members of several of these groups.

• Alcoholics Anonymous and Recovery, Inc. members emphasize the instillation of hope, imparting information, universality, altruism, and some aspects of group cohesiveness.

• Members of discharge planning groups in psychiatric hospitals emphasize imparting of information and development of socializing techniques.

• Participants of occupational therapy groups most valued the factors of cohesiveness, instillation of hope, and interpersonal learning.
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• Members of psychodrama groups in Israel, despite differences in culture and treatment format, selected factors consistent with those selected by group therapy outpatients: interpersonal learning, catharsis, group cohesiveness, and self-understanding.
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• Members of self-help groups (women’s consciousness raising, bereaved parents, widows, heart surgery patients, and mothers) commonly chose factors of universality, followed by guidance, altruism, and cohesiveness.
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• Members of an eighteen-month-long group of spouses caring for a partner with a brain tumor chose universality, altruism, instillation of hope, and the provision of information.
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• Psychotic clients with intrusive, controlling auditory hallucinations successfully treated in cognitive-behavioral therapy groups valued universality, hope, and catharsis. For them, finally being able to talk about their voices and feel understood by peers was of enormous value.
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• Spousal abusers in a psychoeducational group selected the imparting of information as a chief therapeutic factor.
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• Adolescents in learning disability groups cited the effectiveness of “mutual recognition”—of seeing oneself in others and feeling valued and less isolated.
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• Geriatric group participants who confront limits, mortality, and the passage of time select existential factors as critically important.
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When therapists form a new therapy group in some specialized setting or for some specialized clinical population, the first step, as I will stress in chapter 15, is to determine the appropriate goals and, after that, the therapeutic factors most likely to be helpful for that particular group. Everything else, all matters of therapeutic technique, follow from that framework. Thus, it is vitally important to keep in mind the persuasive research evidence that different types of group therapy make use of different therapeutic factors.

For example, consider a time-limited psychoeducational group for panic attacks whose members may receive considerable benefit from group leader instruction on cognitive strategies for preventing and minimizing the disruptiveness of the attacks (guidance). The experience of being in a group of people who suffer from the same problem (universality) is also likely to be very comforting. Although difficulties in relationships may indeed contribute to their symptoms, an undue focus on the therapeutic factor of interpersonal learning would not be warranted given the time frame of the group.

Understanding the client’s experience of the therapeutic factors can lead to enlightened and productive group innovations. For example, an effective multimodal group approach for bulimia nervosa has been reported that integrates and sequences three independently effective treatments. This twelve-week group starts with a psychoeducation module about bulimia and nutrition; next is a cognitive-behavioral module that examines distorted cognitions about eating and body image; and the group concludes with an interpersonally oriented group segment that examines here-and-now relationship concerns and their impact on eating behaviors.
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Therapeutic Factors and Stages of Therapy

Intensive interactional group therapy exerts its chief therapeutic power through interpersonal learning (encompassing catharsis, self-understanding, and interpersonal input and output) and group cohesiveness, but the other therapeutic factors play an indispensable role in the intensive therapy process. To appreciate the interdependence of the therapeutic factors, we must consider the entire group process from start to finish.

Many clients expressed difficulty in rank-ordering therapeutic factors because they found different factors helpful at different stages of therapy. Factors of considerable importance early in therapy may be far less salient late in the course of treatment. Consider the early stages of development: the group’s chief concerns are with survival, establishing boundaries, and maintaining membership. In this phase, factors such as the instillation of hope, guidance, and universality are especially important.†
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A universality phase early in the group is inevitable as well, as members search out similarities and compare symptoms and problem constellations.

The first dozen meetings of a group present a high-risk period for potential dropouts, and it is often necessary to awaken hope in the members in order to keep them attending through this critical phase. Factors such as altruism and group cohesiveness operate throughout therapy, but their nature changes with the stage of the group. Early in therapy, altruism takes the form of offering suggestions or helping one another talk by asking appropriate questions and giving attention. Later it may take the form of a more profound caring and presence.