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Chapter 1

THE THERAPEUTIC

FACTORS

D oes group therapy help clients? Indeed it does. A persuasive body of outcome research has demonstrated unequivocally that group ther­ apy is a highly effective form of psychotherapy and that it is at least equal to individual psychotherapy in its power to provide meaningful benefit. 1

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 ap­ proach the most vexing and controversial problems of psychotherapy. Once identified, the crucial aspects of the process of change will consti­ tute a rational basis for the therapist's selection of tactics and strategies to shape the group experience to maximize its potency with different clients and in different settings.

I suggest that therapeutic change is an enormously complex process that occurs through an intricate interplay of human experiences, which I 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, I begin by describing and discussing these elemental factors.

From my 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

2 THE THERAPEUTIC FACTORS

7. Imitative behavior 8. Interpersonal learning 9. Group cohesiveness

10. Catharsis 11. Existential factors

In the rest of this chapter, I discuss the first seven factors. I consider in­ terpersonal learning and group cohesiveness so important and complex that I have treated 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 interwo­ ven with other therapeutic factors and will also be discussed in chapter 4.

The distinctions among these factors are arbitrary. Although I discuss them singly, they are interdependent and neither occur nor function sepa­ rately. Moreover, these factors may represent different parts of the change process: some factors (for example, interpersonal learning) act at the level of cognition; some (for example, development of socializing techniques) act at the level of behavioral change; some (for example, catharsis) act at the level of emotion; and some (for example, cohesiveness) may be more accurately described as preconditions for change. t Although the same therapeutic factors operate in every type of therapy group, their interplay and differential importance can vary widely from group to group. Fur­ thermore, because of individual differences, participants in the same group benefit from widely different clusters of therapeutic factors. t

Keeping in mind that the therapeutic factors are arbitrary constructs, we can view them as providing a cognitive map for the student-reader. This grouping of the therapeutic factors is not set in concrete; other clin­ icians and researchers have arrived at a different, and also arbitrary, clus­ ter of factors. 2 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. (I will discuss all of these issues more fully in chapter 4.)

The inventory of therapeutic factors I propose issues from my clinical experience, from the experience of other therapists, from the views of the successfully treated group patient, 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 crude and inapplicable.

From the group therapists we obtain a variegated and internally incon­ sistent inventory of therapeutic factors (see chapter 4). Therapists, by no means disinterested or unbiased observers, have invested considerable time and energy in mastering a certain therapeutic approach. Their an­ swers will be determined largely by their particular school of conviction.

3 The Therapeutic Factors

Even among therapists who share the same ideology and speak the same language, there may be no consensus about the reasons clients improve. In research on encounter groups, my colleagues and I learned that many suc­ cessful group leaders attributed their success to factors that were irrele­ vant to the therapy process: for example, the hot-seat technique, or nonverbal exercises, or the direct impact of a therapist's own person (see chapter 16).3 But that does not surprise us. The history of psychotherapy abounds in healers who were effective, but not for the reasons they sup­ posed. At other times we therapists throw up our hands in bewilderment. Who has not had a client who made vast improvement for entirely obscure reasons?

Group members at the end of a course of group therapy can supply data about the therapeutic factors they considered most and least helpful. Yet we know that such evaluations will be incomplete and their accuracy limited. Will the group members not, perhaps, focus primarily on superfi­ cial factors and neglect some profound healing forces that may be beyond their awareness? Will their responses not be influenced by a variety of fac­ tors difficult to control? It is entirely possible, for example, that their views may be distorted by the nature of their relationship to the therapist or to the group. (One team of researchers demonstrated that when pa­ tients were interviewed four years after the conclusion of therapy, they were far more apt to comment on unhelpful or harmful aspects of their group experience than when interviewed immediately at its conclusion.) 4

Research has also shown, for example, that the therapeutic factors valued by group members may differ greatly from those cited by their therapists or by group observers, 5 an observation also made in individual psy­ chotherapy. Furthermore, many confounding factors influence the client's evaluation of the therapeutic factors: for example, the length of time in treatment and the level of a client's functioning, 6 the type of group (that is, whether outpatient, inpatient, day hospital, brief therapy),7 the age and the diagnosis of a client, 8 and the ideology of the group leader. 9 An­ other factor that complicates the search for common therapeutic factors is the extent to which different group members perceive and experience the same event in different ways.t Any given experience may be important or helpful to some and inconsequential or even harmful to others.

Despite these limitations, clients' reports are a rich and relatively un­ tapped source of information. After all, it is their experience, theirs alone, and the farther we move from the clients' experience, the more inferential are 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 do say.

There is an art to obtaining clients' reports. Paper-and-pencil or sort­ ing questionnaires provide easy data but often miss the nuances and the

4 THE THERAPEUTIC FACTORS

richness of the clients' experience. The more the questioner can enter into the experiential world of the client, the more lucid and meaningful the re­ port of the therapy experience becomes. To the degree that the therapist is able to suppress personal bias and avoid influencing the client's re­ sponses, he or she becomes the ideal questioner: the therapist is trusted and understands more than anyone else the inner world of the client.

In addition to therapists' views and clients' reports, there is a third im­ portant method of evaluating the therapeutic factors: the systematic re­ search approach. The most common research strategy by far is to correlate in-therapy variables with outcome in therapy. By discovering which vari­ ables are significantly related to successful outcomes, one can establish a reasonable base from which to begin to delineate the therapeutic factors. However, there are many inherent problems in this approach: the measure­ ment of outcome is itself a methodological morass, and the selection and measurement of the in-therapy variables are equally problematic. ~- 10

I have drawn from all these methods to derive the therapeutic factors discussed in this book. Still, I do not consider these conclusions definitive; rather, I offer them as provisional guidelines that may be tested and deep­ ened by other clinical researchers. For my part, I am satisfied that they de­ rive from the best available evidence at this time and that they constitute the basis of an effective approach to therapy.

INSTILLATION OF HOPE

The instillation and maintenance of hope is crucial in any psychother­ apy. Not only is hope required to keep the client in therapy so that other therapeutic factors may take effect, but faith in a treatment mode can in itself be therapeutically effective. Several studies have demonstrated that a high expectation of help before the start of therapy is significantly correlated with a positive therapy outcome. 11 Consider also the massive data documenting the efficacy of faith healing and placebo treatment­ therapies mediated entirely through hope and conviction. A positive outcome in psychotherapy is more likely when the client and the thera­ pist have similar expectations of the treatment. 12 The power of expecta­ tions extends beyond imagination alone. Recent brain imaging studies demonstrate that the placebo is not inactive but can have a direct physi­ ological effect on the brain. 13

~we are better able to evaluate therapy outcome in general than we are able to measure the re­ lationships between these process variables and outcomes. Kivlighan and colleagues have devel­ oped a promising scale, the Group Helpful Impacts Scale, that tries to capture the entirety of the group therapeutic process in a multidimensional fashion that encompasses therapy tasks and therapy relationships as well as group process, client, and leader variables.

5 Instillation of Hope

Group therapists can capitalize on this factor by doing whatever we can to increase clients' belief and confidence in the efficacy of the group mode. This task begins before the group starts, in the pregroup orienta­ tion, in which the therapist reinforces positive expectations, corrects neg­ ative preconceptions, and presents a lucid and powerful explanation of the group's healing properties. (See chapter 10 for a full discussion of the pregroup preparation procedure.)

Group therapy not only draws from the general ameliorative effects of positive expectations but also benefits from a source of hope that is unique to the group format. Therapy groups invariably contain individu­ als 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 impor­ tant it was for them to have observed the improvement of others. Re­ markably, hope can be a powerful force even in groups of individuals combating advanced cancer who lose cherished group members to the dis­ ease. Hope is flexible--it redefines itself to fit the immediate parameters, becoming hope for comfort, for dignity, for connection with others, or for minimum physical discomfort.14

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

Research has shown that it is also vitally important that therapists be­ lieve in themselves and in the efficacy of their group. 15 I sincerely believe that I am able to help every motivated client who is willing to work in the group for at least six months. In my initial meetings with clients individ­ ually, I share this conviction with them and attempt to imbue them with my optimism.

Many of the self-help groups-for example, Compassionate Friends (for bereaved parents), Men Overcoming Violence (men who batter), Sur­ vivors of Incest, and Mended Heart (heart surgery patients)-place heavy emphasis on the instillation of hope. 16 A major part of Recovery, Inc. (for current and former psychiatric patients) and Alcoholics Anonymous meet­ ings is dedicated to testimonials. At each meeting, members of Recovery, Inc. give accounts of potentially stressful incidents in which they avoided tension by the application of Recovery, Inc. methods, and successful Alco­ holics Anonymous members tell their stories of downfall and then rescue by AA. One of the great strengths of Alcoholics Anonymous is the fact that the leaders are all alcoholics-living inspirations to the others.

6 THE THERAPEUTIC FACTORS

Substance abuse treatment programs commonly mobilize hope in par­ ticipants by using recovered drug addicts as group leaders. Members are inspired and expectations raised by contact with those who have trod the same path and found the way back. A similar approach is used for indi­ viduals with chronic medical illnesses such as arthritis and heart disease. These self-management groups use trained peers to encourage members to cope actively with their medical conditions.17 The inspiration provided to participants by their peers results in substantial improvements in med­ ical outcomes, reduces health care costs, promotes the individual's sense of self-efficacy, and often makes group interventions superior to individ­ ual therapies. 18

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. Of course, there is a core of truth to this notion, since most clients have had an un­ usual constellation of severe life stresses and are periodically flooded by frightening material that has leaked from their unconscious.

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 ex­ periences nor avail themselves of the opportunity to confide in, and ulti­ mately 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 re­ port feeling more in touch with the world and describe the process as a "welcome to the human race" experience. Simply put, the phenomenon finds expression in the cliche "We're all in the same boat"-or perhaps more cynically, "Misery loves company."

There is no human deed or thought that lies fully outside the experi­ ence of other people. I have heard group members reveal such acts as in­ cest, torture, burglary, embezzlement, murder, attempted suicide, and fantasies of an even more desperate nature. Invariably, I have observed other group members reach out and embrace these very acts as within the realm of their own possibilities, often following through the door of dis­ closure opened by one group member's trust or courage. Long ago Freud noted that the staunchest taboos (against incest and patricide) were con­ structed precisely because these very impulses are part of the human being's deepest nature.

7 Universality

Nor is this form of aid limited to group therapy. Universality plays a role in individual therapy also, although in that format there is less op­ portunity for consensual validation, as therapists choose to restrict their degree of personal transparency.

During my own 600-hour analysis I had a striking personal encounter with the therapeutic factor of universality. It happened when I was in the midst of describing my extremely ambivalent feelings toward my mother. I was very much troubled by the fact that, despite my strong positive sen­ timents, I was also beset with death wishes for her, as I stood to inherit part of her estate. My analyst responded simply, "That seems to be the way we're built." That artless statement not only offered me considerable relief but enabled me to explore my ambivalence in great depth.

Despite the complexity of human problems, certain common denomi­ nators between individuals are clearly evident, and the members of a ther­ apy group soon perceive their similarities to one another. An example is illustrative: For many years I asked members of T-groups (these are non­ clients-primarily medical students, psychiatric residents, nurses, psychi­ atric technicians, and Peace Corps volunteers; see chapter 16) to engage in a "top-secret" task in which they were asked to write, anonymously, on a slip of paper the one thing they would be most disinclined to share with the group. The secrets prove to be startlingly similar, with a couple of major themes predominating. The most common secret is a deep convic­ tion of basic inadequacy-a feeling that one is basically incompetent, that one bluffs one's way through life. Next in frequency is a deep sense of interpersonal alienation-that, despite appearances, one really does not, or cannot, care for or love another person. The third most frequent cate­ gory is some variety of sexual secret. These chief concerns of nonclients are qualitatively the same in individuals seeking professional help. Almost invariably, our clients experience deep concern about their sense of worth and their ability to relate to others.'~

Some specialized groups composed of individuals for whom secrecy has been an especially important and isolating factor place a particularly great emphasis on universality. For example, short-term structured groups for bulimic clients build into their protocol a strong requirement for self­ disclosure, especially disclosure about attitudes toward body image and detailed accounts of each member's eating rituals and purging practices. With rare exceptions, patients express great relief at discovering that they are not alone, that others share the same dilemmas and life experiences.19

'There are several methods of using such information in the work of the group. One effective technique is to redistribute the anonymous secrets to the members, each one receiving another's secret. Each member is then asked to read the secret aloud and reveal how he or she would feel if harboring such a secret. This method usually proves to be a valuable demonstration of uni­ versaliry, empathy, and the ability of others to understand.

8 THE THERAPEUTIC FACTORS

Members of sexual abuse groups, too, profit enormously from the ex­ perience of universality. 20 An integral part of these groups is the intimate sharing, often for the first time in each member's life, of the details of the abuse and the ensuing internal devastation they suffered. Members in such groups can encounter others who have suffered similar violations as children, who were not responsible for what happened to them, and who have also suffered deep feelings of shame, guilt, rage, and uncleanness. A feeling of universality is often a fundamental step in the therapy of clients burdened with shame, stigma, and self-blame, for example, clients with HIV/AIDS or those dealing with the aftermath of a suicide. 21

Members of homogeneous groups can speak to one another with a powerful authenticity that comes from their firsthand experience in ways that therapists may not be able to do. For instance, I once supervised a thirty-five-year-old therapist who was leading a group of depressed men in their seventies and eighties. At one point a seventy-seven-year-old man who had recently lost his wife expressed suicidal thoughts. The therapist hesitated, fearing that anything he might say would come across as naive. Then a ninety-one-year-old group member spoke up and described how he had lost his wife of sixty years, had plunged into a suicidal despair, and had ultimately recovered and returned to life. That statement resonated deeply and was not easily dismissed.

In multicultural groups, therapists may need to pay particular attention to the clinical factor of universality. Cultural minorities in a predomi­ nantly Caucasian group may feel excluded because of different cultural attitudes toward disclosure, interaction, and affective expression. Thera­ pists must help the group move past a focus on concrete cultural differ­ ences to transcultural-that is, universal-responses to human situations and tragedies. 22 At the same time, therapists must be keenly aware of the cultural factors at play. Mental health professionals are often sorely lack­ ing in knowledge of the cultural facts of life required to work effectively with culturally diverse members. It is imperative that therapists learn as much as possible about their clients' cultures as well as their attachment to or alienation from their culture. 23

Universality, like the other therapeutic factors, does not have sharp bor­ ders; it merges with other therapeutic factors. As clients perceive their similarity to others and share their deepest concerns, they benefit further from the accompanying catharsis and from their ultimate acceptance by other members (see chapter 3 on group cohesiveness).

IMPARTING INFORMATION

Under the general rubric of imparting information, I include didactic in­ struction about mental health, mental illness, and general psychodynam-

9 Imparting Information

ics given by the therapists as well as advice, suggestions, or direct guid­ ance from either the therapist or other group members.

Didactic Instruction

Most pa'rticipants, at the conclusion of successful interactional group therapy, have learned a great deal about psychic functioning, the meaning of symptoms, interpersonal and group dynamics, and the process of psy­ chotherapy. Generally, the educational process is implicit; most group therapists do not offer explicit didactic instruction in interactional group therapy. Over the past decade, however, many group therapy approaches have made formal instruction, or psychoeducation, an important part of the program.

One of the more powerful historical precedents for psychoeducation can be found in the work of Maxwell Jones, who in his work with large groups in the 1940s lectured to his patients three hours a week about the nervous system's structure, function, and relevance to psychiatric symp­ toms and disability.24

Marsh, writing in the 1930s, also believed in the importance of psy­ choeducation and organized classes for his patients, complete with lec­ tures, homework, and grades.25

Recovery, Inc., the nation's oldest and largest self-help program for cur­ rent and former psychiatric patients, is basically organized along didactic lines. 26 Founded in 1937 by Abraham Low, this organization has over 700 operating groups today. 27 Membership is voluntary, and the leaders spring from the membership. Although there is no formal professional guidance, the conduct of the meetings has been highly structured by Dr. Low; parts of his textbook, Me_ntal Health Through Will Training, 28 are read aloud and discussed at every meeting. Psychological illness is explained on the basis of a few simple principles, which the members memorize-for ex­ ample, the value of "spotting" troublesome and self-undermining behav­ iors; that neurotic symptoms are distressing but not dangerous; that tension intensifies and sustains the symptom and should be avoided; that the use of one's free will is the solution to the nervous patient's dilemmas.

Many other self-help groups strongly emphasize the imparting of in­ formation. Groups such as Adult Survivors of Incest, Parents Anony­ mous, Gamblers Anonymous, Make Today Count (for cancer patients), Parents Without Partners, and Mended Hearts encourage the exchange of information among members and often invite experts to address the group. 29 The group environment in which learning takes place is impor­ tant. The ideal context is one of partnership and collaboration, rather than prescription and subordination.

Recent group therapy literature abounds with descriptions of special­ ized groups for individuals who have some specific disorder or face some

10 THE THERAPEUTIC FACTORS

definitive life crisis-for example, panic disorder,30 obesity, 31 bulimia,32 adjustment after divorce, 33 herpes,34 coronary heart disease,35 parents of sexually abused children,36 male batterers,37 bereavement,38 HIV/AIDS,39 sexual dysfunction, 40 rape, 41 self-image adjustment after mastectomy,42 chronic pain,43 organ transplant,44 and prevention of depression relapse. 45

In addition to offering mutual support, these groups generally build in a psychoeducational component approach offering explicit instruction about the nature of a client's illness or life situation and examining clients' misconceptions and self-defeating responses to their illness. For example, the leaders of a group for clients with panic disorder describe the physiological cause of panic attacks, explaining that heightened stress and arousal increase the flow of adrenaline, which may result in hyperventilation, shortness of breath, and dizziness; the client misinter­ prets the symptoms in ways that only exacerbate them ("I'm dying" or "I'm going crazy"), thus perpetuating a vicious circle. The therapists dis­ cuss the benign nature of panic attacks and offer instruction first on how to bring on a mild attack and then on how to prevent it. They provide de­ tailed instruction on proper breathing techniques and progressive muscu­ lar relaxation.

Groups are often the setting in which new mindfulness- and medita­ tion-based stress reduction approaches are taught. By applying disciplined focus, members learn to become clear, accepting, and nonjudgmental ob­ servers of their thoughts and feelings and to reduce stress, anxiety, and vulnerability to depression. 46

Leaders of groups for HIV-positive clients frequently offer considerable illness-related medical information and help correct members' irrational fears and misconceptions about infectiousness. They may also advise members about methods of informing others of their condition and fash­ ioning a less guilt-provoking lifestyle.

Leaders of bereavement groups may provide information about the natural cycle of bereavement to help members realize that there is a se­ quence of pain through which they are progressing and there will be a natural, almost inevitable, lessening of their distress as they move through the stages of this sequence. Leaders may help clients anticipate, for exam­ ple, the acute anguish they will feel with each significant date (holidays, anniversaries, and birthdays) during the first year of bereavement. Psy­ choeducational groups for women with primary breast cancer provide members with information about their illness, treatment options, and fu­ ture risks as well as recommendations for a healthier lifestyle. Evaluation of the outcome of these groups shows that participants demonstrate sig­ nificant and enduring psychosocial benefits.47

Most group therapists use some form of anticipatory guidance for clients about to enter the frightening situation of the psychotherapy

11 Imparting Information

group, such as a preparatory session intended to clarify important rea­ sons for psychological dysfunction and to provide instruction in meth­ ods of self-exploration. 48 By predicting clients' fears, by providing them with a cognitive structure, we help them cope more effectively with the culture shock they may encounter when they enter the group therapy (see chapter 10).

Didactic instruction has thus been employed in a variety of fashions in group therapy: to transfer information, to alter sabotaging thought pat­ terns, to structure the group, to explain the process of illness. Often such instruction functions as the initial binding force in the group, until other therapeutic factors become operative. In part, however, explanation and clarification function as effective therapeutic agents in their own right. Human beings have always abhorred uncertainty and through the ages have sought to order the universe by providing explanations, primarily re­ ligious or scientific. The explanation of a phenomenon is the first step to­ ward its control. If a volcanic eruption is caused by a displeased god, then at least there is hope of pleasing the god.

Frieda Fromm-Reichman underscores the role of uncertainty in pro­ ducing anxiety. The awareness that one is not one's own helmsman, she points out, that one's perceptions and behavior are controlled by irra­ tional forces, is itself a common and fundamental source of anxiety. 49

Our contemporary world is one in which we are forced to confront fear and anxiety often. In particular, the events of September 11, 2001, have brought these troubling emotions more clearly to the forefront of people's lives. Confronting traumatic anxieties with active coping (for instance, engaging in life, speaking openly, and providing mutual support), as op­ posed to withdrawing in demoralized avoidance, is enormously helpful. These responses not only appeal to our common sense but, as contempo­ rary neurobiological research demonstrates, these forms of active coping activate important neural circuits in the brain that help regulate the body's stress reactions.50

And so it is with psychotherapy clients: fear and anxiety that stem from uncertainty of the source, meaning, and seriousness of psychiatric symp- · toms may so compound the total dysphoria that effective exploration be­ comes vastly more difficult. Didactic instruction, through its provision of structure and explanation, has intrinsic value and deserves a place in our repertoire of therapeutic instruments (see chapter 5).

Direct Advice

Unlike explicit didactic instruction from the therapist, direct advice from the members occurs without exception in every therapy group. In dy­ namic interactional therapy groups, it is invariably part of the early life of the group and occurs with such regularity that it can be used to estimate

12 THE THERAPEUTIC FACTORS

a group's age. If I observe or hear a tape of a group in which the clients with some regularity say things like, "I think you ought to ... " or "What you should do is ..." or "Why don't you ... ?" then I can be reasonably certain either that the group is young or that it is an older group facing some difficulty that has impeded its development or effected temporary regression. In other words, advice-giving may reflect a resistance to more intimate engagement in which the group members attempt to manage re­ lationships rather than to connect. Although advice-giving is common in early interactional group therapy, it is rare that specific advice will directly benefit any client. Indirectly, however, advice-giving serves a purpose; the process of giving it, rather than the content of the advice, may be benefi­ cial, implying and conveying, as it does, mutual interest and caring.

Advice-giving or advice-seeking behavior is often an important clue in the elucidation of interpersonal pathology. The client who, for example, continuously pulls advice and suggestions from others, ultimately only to reject them and frustrate others, is well known to group therapists as the "help-rejecting complainer" or the "yes ... but" client (see chapter 13).51

Some group members may bid for attention and nurturance by asking for suggestions about a problem that either is insoluble or has already been solved. Others soak up advice with an unquenchable thirst, yet never rec­ iprocate to others who are equally needy. Some group members are so in­ tent on preserving a high-status role in the group or a facade of cool self-sufficiency that they never ask directly for help; some are so anxious to please that they never ask for anything for themselves; some are exces­ sively effusive in their gratitude; others never acknowledge the gift but take it home, like a bone, to gnaw on privately.

Other types of more structured groups that do not focus on member interaction make explicit and effective use of direct suggestions and guid­ ance. For example, behavior-shaping groups, hospital discharge planning and transition groups, life skills groups, communicational skills groups, Recovery, Inc., and Alcoholics Anonymous all proffer considerable direct advice. One communicational skills group for clients who have chronic psychiatric illnesses reports excellent results with a structured group pro­ gram that includes focused feedback, videotape playback, and problem­ solving projects. 52 AA makes use of guidance and slogans: for example, members are asked to remain abstinent for only the next twenty-four hours-"One day at a time." Recovery, Inc. teaches members how to spot neurotic symptoms, how to erase and retrace, how to rehearse and re­ verse, and how to apply willpower effectively.

Is some advice better than others? Researchers who studied a behavior­ shaping group of male sex offenders noted that advice was common and was useful to different members to different extents. The least effective form of advice was a direct suggestion; most effective was a series of al-

13 Altruism

ternative suggestions about how to achieve a desired goal. 53 Psychoeduca­ tion about the impact of depression on family relationships is much more effective when participants examine, on a direct, emotional level, the way depression is affecting their own lives and family relationships. The same information presented in an intellectualized and detached manner is far less valuable,54

ALTRUISM

There is an old Hasidic story of a rabbi who had a conversation with the Lord about Heaven and Hell. "I will show you Hell," said the Lord, and led the rabbi into a room containing a group of famished, desperate peo­ ple sitting around a large, circular table. In the center of the table rested an enormous pot of stew, more than enough for everyone. The smell of the stew was delicious and made the rabbi's mouth water. Yet no one ate. Each diner at the table held a very long-handled spoon-long enough to reach the pot and scoop up a spoonful of stew, but too long to get the food into one's mouth. The rabbi saw that their suffering was indeed ter­ rible and bowed his head in compassion. "Now I will show you Heaven," said the Lord, and they entered another room, identical to the first-same large, round table, same enormous pot of stew, same long-handled spoons. Yet there was gaiety in the air; everyone appeared well nourished, plump, and exuberant. The rabbi could not understand and looked to the Lord. "It is simple," said the Lord, "but it requires a certain skill. You see, the people in this room have learned to feed each other!"~·

In therapy groups, as well as in the story's imagined Heaven and Hell, members gain through giving, not only in receiving help as part of the rec­ iprocal giving-receiving sequence, but also in profiting from something in­ trinsic to the act of giving. Many psychiatric patients beginning therapy are demoralized and possess a deep sense of having nothing of value to offer others. They have long considered themselves as burdens, and the experience of finding that they can be of importance to others is refresh­ ing and boosts self-esteem. Group therapy is unique in being the only therapy that offers clients the opportunity to be of benefit to others. It also encourages role versatility, requiring clients to shift between roles of help receivers and help providers. 55

*In 1973, a member opened the first meeting of the first group ever offered for advanced cancer patients by distributing this parable to the other members of the group. This woman (whom I've written about elsewhere, referring to her as Paula West; see I. Yalom, Momma and the Mean­ ing of Life [New York: Basic Books, 1999]) had been involved with me from the beginning in conceptualizing and organizing this group (see also chapter 15). Her parable proved to be pre­ scient, since many members were to benefit from th~ therapeutic factor of altruism.

14 THE THERAPEUTIC FACTORS

And, of course, clients are enormously helpful to one another in the group therapeutic process. They offer support, reassurance, suggestions, insight; they share similar problems with one another. Not infrequently group members will accept observations from another member far more readily than from the group therapist. For many clients, the therapist re­ mains the paid professional; the other members represent the real world and can be counted on for spontaneous and truthful reactions and feed­ back. Looking back over the course of therapy, almost all group members credit other members as having been important in their improvement. Sometimes they cite their explicit support and advice, sometimes their simply having been present and allowing their fellow members to grow as a result of a facilitative, sustaining relationship. Through the experience of altruism, group members learn firsthand that they have obligations to those from whom they wish to receive care.

An interaction between two group members is illustrative. Derek, a chronically anxious and isolated man in his forties who had recently joined the group, exasperated the other members by consistently dismiss­ ing their feedback and concern. In response, Kathy, a thirty-five-year-old woman with chronic depression and substance abuse problems, shared with him a pivotal lesson in her own group experience. For months she had rebuffed the concern others offered because she felt she did not merit it. Later, after others informed her that her rebuffs were hurtful to them, she made a conscious decision to be more receptive to gifts offered her and soon observed, to her surprise, that she began to feel much better. In other words, she benefited not only from the support received but also in her ability to help others feel they had something of value to offer. She hoped that Derek could consider those possibilities for himself.

Altruism is a venerable therapeutic factor in other systems of healing. In primitive cultures, for example, a troubled person is often given the task of preparing a feast or performing some type of service for the community. 56

Altruism plays an important part in the healing process at Catholic shrines, such as Lourdes, where the sick pray not only for themselves but also for one another. People need to feel they are needed and useful. It is commonplace for alcoholics to continue their AA contacts for years after achieving complete sobriety; many members have related their cautionary story of downfall and subsequent reclamation at least a thousand times and continually enjoy the satisfaction of offering help to others.

Neophyte group members do not at first appreciate the healing impact of other members. In fact, many prospective candidates resist the sugges­ tion of group therapy with the question "How can the blind lead the blind?" or "What can I possibly get from others who are as confused as I am? We'll end up pulling one another down." Such resistance is best worked through by exploring a client's critical self-evaluation. Generally,

15 The Corrective Recapitulation of the Primary Family Group

an individual who deplores the prospect of getting help from other group members is really saying, "I have nothing of value to offer anyone."

There is another, more subtle benefit inherent in the altruistic act. Many clients who complain of meaninglessness are immersed in a morbid self-absorption, which takes the form of obsessive introspection or a teeth-gritting effort to actualize oneself. I agree with Victor Frankl that a sense of life meaning ensues but cannot be deliberately pursued: life meaning is always a derivative phenomenon that materializes when we have transcended ourselves, when we have forgotten ourselves and become absorbed in someone (or something) outside ourselves.57 A focus on life meaning and altruism are particularly important components of the group psychotherapies provided to patients coping with life-threatening medical illnesses such as cancer and AIDS. t 58

THE CORRECTIVE RECAPITULATION OF THE PRIMARY FAMILY GROUP

The great majority of clients who enter groups-with the exception of those suffering from posttraumatic stress disorder or from some medical or environmental stress-have a background of a highly unsatisfactory experience in their first and most important group: the primary family. The therapy group resembles a family in many aspects: there are author­ ity/parental figures, peer/sibling figures, deep personal revelations, strong emotions, and deep intimacy as well as hostile, competitive feelings. In fact, therapy groups are often led by a male and female therapy team in a deliberate effort to simulate the parental configuration as closely as possi­ ble. Once the initial discomfort is overcome, it is inevitable that, sooner or later, the members will interact with leaders and other members in modes reminiscent of the way they once interacted with parents and siblings.

If the group leaders are seen as parental figures, then they will draw re­ actions associated with parental/authority figures: some members become helplessly dependent on the leaders, whom they imbue with unrealistic knowledge and power; others blindly defy the leaders, who are perceived as infantilizing and controlling; others are wary of the leaders, who they believe attempt to strip members of their individuality; some members try to split the co-therapists in an attempt to incite parental disagreements and rivalry; some disclose most deeply when one of the co-therapists is away; some compete bitterly with other members, hoping to accumulate units of attention and caring from the therapists; some are enveloped in envy when the leader's attention is focused on others: others expend en­ ergy in a search for allies among the other members, in order to topple the therapists; still others neglect their own interests in a seemingly selfless ef­ fort to appease the leaders and the other members.

16 THE THERAPEUTIC FACTORS

Obviously, similar phenomena occur in individual therapy, but the group provides a vastly greater number and variety of recapitulative pos­ sibilities. In one of my groups, Betty, a member who had been silently pouting for a couple of meetings, bemoaned the fact that she was not in one-to-one therapy. She claimed she was inhibited because she knew the group could not satisfy her needs. She knew she could speak freely of her­ self in a private conversation with the therapist or with any one of the members. When pressed, Betty expressed her irritation that others were favored over her in the group. For example, the group had recently wel­ comed another member who had returned from a vacation, whereas her return from a vacation went largely unnoticed by the group. Furthermore, another group member was praised for offering an important interpreta­ tion to a member, whereas she had made a similar statement weeks ago that had gone unnoticed. For some time, too, she had noticed her growing resentment at sharing the group time; she was impatient while waiting for the floor and irritated whenever attention was shifted away from her.

Was Betty right? Was group therapy the wrong treatment for her? Ab­ solutely not! These very criticisms-which had roots stretching down into her early relationships with her siblings-did not constitute valid objec­ tions to group therapy. Quite the contrary: the group format was particu­ larly valuable for her, since it allowed her envy and her craving for attention to surface. In individual therapy-where the therapist attends to the client's every word and concern, and the individual is expected to use up all the allotted time-these particular conflicts might emerge belatedly, if at all.

What is important, though, is not only that early familial conflicts are relived but that they are relived correctively. Reexposure without repair only makes a bad situation worse. Growth-inhibiting relationship pat­ terns must not be permitted to freeze into the rigid, impenetrable system that characterizes many family structures. Instead, fixed roles must be constantly explored and challenged, and ground rules that encourage the investigation of relationships and the testing of new behavior must be es­ tablished. For many group members, then, working out problems with therapists and other members is also working through unfinished business from long ago. (How explicit the working in the past need be is a complex and controversial issue, which I will address in chapter 5.)

DEVELOPMENT OF SOCIALIZING TECHNIQUES

Social learning-the development of basic social skills-is a therapeutic factor that operates in all therapy groups, although the nature of the skills taught and the explicitness of the process vary greatly, depending on the type of group therapy. There may be explicit emphasis on the develop-

17 Imitative Behavior

ment of social skills in, for example, groups preparing hospitalized pa­ tients for discharge or adolescent groups. Group members may be asked to role-play approaching a prospective employer or asking someone out on a date.

In other groups, social learning is more indirect. Members of dynamic therapy groups, which have ground rules encouraging open feedback, may obtain considerable information about maladaptive social behavior. A member may, for example, learn about a disconcerting tendency to avoid looking at the person with whom he or she is conversing; about others' impressions of his or her haughty, regal attitude; or about a variety of other social habits that, unbeknownst to the group member, have been undermining social relationships. For individuals lacking intimate rela­ tionships, the group often represents the first opportunity for accurate in­ terpersonal feedback. Many lament their inexplicable loneliness: group therapy provides a rich opportunity for members to learn how they con­ tribute to their own isolation and loneliness. 59

One man, for example, who had been aware for years that others avoided social contact with him, learned in the therapy group that his ob­ sessive inclusion of minute, irrelevant details in his social conversation was exceedingly off-putting. Years later he told me that one of the most important events of his life was when a group member (whose name he had long since forgotten) told him, "When you talk about your feelings, I like you and want to get closer; but when you start talking about facts and details, I want to get the hell out of the room!"

I do not mean to oversimplify; therapy is a complex process and obvi­ ously involves far more than the simple recognition and conscious, delib­ erate alteration of social behavior. But, as I will show in chapter 3, these gains are more than fringe benefits; they are often instrumental in the ini­ tial phases of therapeutic change. They permit the clients to understand that there is a huge discrepancy between their intent and their actual im­ pact on others. t

Frequently senior members of a therapy group acquire highly sophisti­ cated social skills: they are attuned to process (see chapter 6); they have learned how to be helpfully responsive to others; they have acquired meth­ ods of conflict resolution; they are less likely to be judgmental and are more capable of experiencing and expressing accurate empathy. These skills cannot but help to serve these clients well in future social interac­ tions, and they constitute the cornerstones of emotional intelligence. 60

IMITATIVE BEHAVIOR

Clients during individual psychotherapy may, in time, sit, walk, talk, and even think like their therapists. There is considerable evidence that group

18 THE THERAPEUTIC FACTORS

therapists influence the communicational patterns in their groups by modeling certain behaviors, for example, self-disclosure or support. 61 In groups the imitative process is more diffuse: clients may model them­ selves on aspects of the other group members as well as of the thera­ pist. 62 Group members learn from watching one another tackle problems. This may be particularly potent in homogeneous groups that focus on shared problems-for example, a cognitive-behavior group that teaches psychotic patients strategies to reduce the intensity of auditory hallucinations. 63

The importance of imitative behavior in the therapeutic process is dif­ ficult to gauge, but social-psychological research suggests that therapists may have underestimated it. Bandura, who has long claimed that social learning cannot be adequately explained on the basis of direct reinforce­ ment, has experimentally demonstrated that imitation is an effective ther­ apeutic force.t 64 In group therapy it is not uncommon for a member to benefit by observing the therapy of another member with a similar prob­ lem constellation-a phenomenon generally referred to as vicarious or spectator therapy. 65

Imitative behavior generally plays a more important role in the early stages of a group, as members identify with more senior members or ther­ apists. 66 Even if imitative behavior is, in itself, short-lived, it may help to unfreeze the individual enough to experiment with new behavior, which in turn can launch an adaptive spiral (see chapter 4). In fact, it is not un­ common for clients throughout therapy to "try on," as it were, bits and pieces of other people and then relinquish them as ill fitting. This process may have solid therapeutic impact; finding out what we are not is progress toward finding out what we are.