ANNOTATED BIBLIOGRAPHY

Create an annotated bibliography of at least seven scholarly, peer reviewed journal articles (books should not be used) published within the last three years. 

These sources should directly relate to the selected psychotherapy group topic and reflect the current research on group psychotherapy practices, theories, and interventions. 

Each entry must follow current professional APA formatting guidelines and include a brief annotation summarizing the source and its relevance to your project. It is important that these are summaries of the content and do not include direct quotes. 

Attached copy of the psychotherapy group topic

EDCO 711

Psychotherapy Group Advertisement Assignment Instructions

Overview 

This assignment offers an opportunity to transition from a psychoeducational group to a psychotherapy group focus. The task is to create a recruitment flyer for your psychotherapy group, aimed at attracting appropriate participants. This flyer should reflect a professional tone, clear communication, and adherence to ethical considerations in group therapy recruitment.

Instructions 

Students will build upon the topic selected in
Psychoeducational Group Plan Assignment as the course shifts to focus on developing a psychotherapy group. The first step in this process is to create a recruitment flyer that effectively communicates the purpose and structure of the group while attracting suitable members. The flyer must include the following components:

1. Brief Description of the Group’s Topic
Provide a concise yet compelling summary of the psychotherapy group’s topic, highlighting its relevance and importance. This section should clearly convey the purpose of the group and why potential participants would benefit from joining. Infusion of scholarly evidence is required when describing the group’s topic and importance, with an emphasis on synthesizing the references utilized.

2. Participant Inclusion/Exclusion Criteria
Specify the criteria for participation, including both inclusion and exclusion guidelines. This ensures that the group composition aligns with the therapeutic goals and ethical guidelines of group therapy.

3. Type of Group
Indicate whether the group will be open or closed, homogeneous or heterogeneous. This information is critical in helping potential participants understand the group’s dynamics and structure.

4. Setting and Structure
Outline the logistical aspects of the group, including the physical or virtual setting, the frequency of meetings, and the duration of the group. These details are essential for participants to understand the commitment involved.

5. Pre-Group Meetings or Preparation
Include any information about any pre-group meetings or other preparatory steps required for participants. This helps to ensure that group members are adequately prepared for the therapy process.

Formatting and Design
The flyer should be visually appealing, clear, and professional with proper credit given to any graphics or resources used. Ensure the information is well-organized, concise, and easy to read. Due to the brief nature of an advertisement, no direct quotes should be utilized. The flyer should be one page in length, at lest one reference must be used to describe the group’s topic.

Assessment
Your assignment will be evaluated based on the clarity, professionalism, and effectiveness of the advertisement in communicating essential information to potential group members.

Note: The assignment will be checked for originality via the Turnitin plagiarism tool.

Watch from 1:05:35 to 1:23:15.

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Read: Yalom: Chapters 3, 7 – 9

Yalom, I. D., Leszcz, M. (2020-12-01). The Theory and Practice of Group Psychotherapy, 6th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9781541617568

Chapters 3

Group Cohesiveness
IN THIS CHAPTER WE EXAMINE THE PROPERTIES OF COHESIVENESS, the considerable evidence for group cohesiveness as a therapeutic factor, and the various pathways through which cohesiveness exerts its therapeutic influence.
What is cohesiveness and how does it influence therapeutic outcome? The short answer is that cohesiveness is the group therapy analogue to the relationship in individual therapy. First, keep in mind that a vast body of research on individual psychotherapy demonstrates that a good therapist-client relationship is essential for a positive outcome. The link between the therapeutic alliance and outcome is one of the most reliable research findings in our field.1 Is it also true that a good therapy relationship is essential in group therapy? Here again, the literature leaves little doubt that “relationship” is germane to positive outcome in group therapy.2 But relationship in group therapy is a far more complex concept than relationship in individual therapy. After all, there are only two people in the individual therapy relationship, whereas a number of individuals, generally six to ten, work together in group therapy. Hence it is insufficient to say that a good relationship is necessary for successful group therapy—we must also specify which relationship: The relationship between the client and the group therapist (or therapists, if there are co-leaders)? Or between the group member and other members? Or perhaps even between the individual and the “group” taken as a whole? In other words, there are intrapersonal, interpersonal, and group variables to consider as well.3

Over the past sixty years, a vast number of controlled studies of psychotherapy outcome have demonstrated that the average person who receives psychotherapy is significantly improved and that the outcome from group therapy is virtually identical to that of individual therapy.4 Furthermore, there is evidence that certain clients may obtain greater benefit from group therapy than from other approaches, particularly clients dealing with stigma or social isolation and those seeking new coping skills.5

The evidence supporting the effectiveness of group psychotherapy is so compelling that it prompts us to direct our attention toward another question: What are the necessary conditions for effective psychotherapy? After all, not all psychotherapy is successful. In fact, there is evidence that treatment may be for better or for worse—although most therapists help their clients, some therapists make some clients worse.6 Why? What are the characteristics of a successful therapist? Although many factors are involved, effective therapists are empathically attuned to their clients and are able to provide an understandable, culturally resonant explanation of distress and its treatment that in turn builds the client’s self-efficacy.7 Research evidence overwhelmingly supports the conclusion that successful therapy—indeed, even successful pharmacotherapy treatment—is mediated by a relationship between treater and client that is characterized by agreement on the goals and tasks of treatment and marked by trust, warmth, empathic understanding, and acceptance.8

Although a positive therapeutic alliance is common to all effective treatments, it is by no means easily or routinely established. Extensive therapy research has focused on the nature of the therapeutic alliance and the specific interventions required to achieve, maintain, and repair the alliance when it gets strained or frayed.9

Is the quality of the relationship related to the therapist’s theoretical orientation? The evidence says no. Effective clinicians from different schools (psychodynamic, psychoanalytic, emotion-focused, humanistic, interpersonal, cognitive-behavioral) resemble one another (and differ from nonexperts in their own school) in their conception of the ideal therapeutic relationship and in the relationship they themselves establish with their clients.10

Note that the engaged, cohesive therapeutic relationship is necessary in all effective psychotherapies, even in the so-called mechanistic approaches—cognitive, behavioral, or systems-oriented forms of psychotherapy.11 One of the first large comparative psychotherapy trials, the National Institute of Mental Health’s (NIMH) Treatment of Depression Collaborative Research Program, concluded that successful cognitive-behavioral therapy or interpersonal therapy required “the presence of a positive attachment to a benevolent, supportive, and reassuring authority figure.”12 Research has shown that the client-therapist bond and the technical elements of cognitive therapy are synergistic: a strong and positive bond in itself disconfirms depressive beliefs and facilitates the work of modifying cognitive distortions. The absence of a positive bond renders technical interventions ineffective or even harmful.13 The experience the client has of the treater is of enormous importance and is a good predictor of outcome.14 And this experience emerges in large part from the therapist’s actions and use of self.15 More and more, these core therapist relationship capacities are being recognized as key foci in training programs.16

As noted, relationship plays an equally critical role in group psychotherapy. But the group therapy analogue of the client-therapist relationship in individual therapy must be a broader concept, encompassing the individual’s relationship to the group therapist, to the other group members, and to the group as a whole. In this text we refer to all of these relationships with the term “group cohesiveness.” Cohesiveness is a widely researched basic property of groups that has been explored in several hundred research articles, reviews, and meta-analytic studies synthesizing huge data pools.17 Unfortunately, there is little cohesion in the cohesion literature, which suffers from the lack of replication studies and the use of different definitions, scales, subjects, and rater perspectives.18

In general, however, the studies agree that groups differ from one another in the amount of “groupness” present. Those with a greater sense of solidarity, or “we-ness,” value the group more highly and have higher attendance, participation, and mutual support. Nonetheless, it is difficult to formulate a precise definition. A thoughtful review concluded that cohesiveness “is like dignity: everyone can recognize it but apparently no one can describe it, much less measure it.”19 The problem is that cohesiveness refers to overlapping dimensions. On the one hand, there is a group phenomenon—the total esprit de corps; on the other hand, there is the individual member cohesiveness (or, more strictly, the individual’s attraction to the group and to the leader).20 Furthermore, both the client’s emotional experience and the sense of task effectiveness in the group contribute to cohesion.21

In this book, we define cohesiveness as the attractiveness of a group for its members.22 Members of a cohesive group feel warmth and comfort in the group and a sense of belonging; they value the group and feel they are valued, accepted, and supported by other members.23

Esprit de corps and individual cohesiveness are interdependent, and group cohesiveness is sometimes computed simply by summing the individual members’ level of attraction to the group. Newer, more sophisticated methods of measuring group cohesiveness, such as the Group Questionnaire (GQ) developed by Gary Burlingame and colleagues, are gaining prominence and promise a more valid and reliable assessment of group cohesion.i

The more we examine cohesiveness, the more complexity we encounter. For example, we now know that each client’s view of cohesiveness is impacted by the group cohesiveness other members feel. Group cohesiveness is generally considered as a summation of the individual members’ sense of belonging, but we have also learned that group members are differentially attracted to the group—personality, interpersonal patterns, and attachment style all play a large role.24 Furthermore, while cohesiveness is not fixed but instead fluctuates greatly during the course of the group, we know that early cohesion is essential in setting the stage for the more challenging work to follow.25 Research has also differentiated between the members’ sense of belonging and their appraisal of how well the entire group is working. It is not uncommon for an individual to feel “that this group works well, but I’m not part of it.”26 It is also possible for members (for example, eating disorder clients) to value the interaction and bonding in the group yet be fundamentally opposed to the group goal.

Before leaving the matter of definition, we must point out that group cohesiveness is not only a potent therapeutic force in its own right; it is a precondition for other therapeutic factors to function optimally. When, in individual therapy, we say that it is the relationship that heals, we do not mean that love or loving acceptance is enough; we mean that an ideal therapist-client relationship creates conditions in which the necessary risk-taking, self-disclosure, catharsis, and intrapersonal and interpersonal exploration may unfold. It is the same for group therapy: Cohesiveness is necessary for other group therapeutic factors to operate.

THE IMPORTANCE OF GROUP COHESIVENESS
Although we discuss the therapeutic factors separately, they are, to a great degree, interdependent. Catharsis and universality, for example, are not complete processes. It is not the sheer process of ventilation, or the discovery that others have problems similar to one’s own, and the ensuing disconfirmation of one’s wretched uniqueness, that are important: it is the affective sharing of one’s inner world and then the acceptance by others that seems of paramount importance. To be accepted by others challenges the client’s belief that he or she is basically repugnant, unacceptable, or unlovable. The need for belonging is innate in all of us. Both affiliation within the group and attachment in the individual setting address this need.27 Therapy groups generate a positive, self-reinforcing loop: trust–self-disclosure–empathy–acceptance–trust.28 If norms of nonjudgmental acceptance and inclusiveness are established early and the member adheres to the group’s procedural norms, a member will be accepted by the group regardless of past transgressions, social failings, alternative lifestyles, or substance abuse or a history of prostitution or criminal offenses.

For the most part, the flawed interpersonal skills of our clients have limited their opportunities for effective sharing in either one-to-one relationships or groups. Not infrequently, the therapy group offers isolated clients their only deeply human contact. After just a few sessions, members often have a stronger sense of being at home in the group than anywhere else. Later, even years afterward, when most other recollections of the group have faded from memory, they may still remember this warm sense of belonging and acceptance.

As one successful client looking back over two and a half years of group therapy put it, “the most important thing in it was just having a group there, people that I could always talk to, that wouldn’t walk out on me. There was so much caring and hating and loving in the group, and I was a part of it. I’m better now and have my own life, but it’s sad to think that the group’s not there anymore.”

Furthermore, group members see that they are not just passive beneficiaries of group cohesion; they also generate that cohesion and create durable relationships—perhaps for the first time in their lives. One group member commented that he had always attributed his aloneness to some unidentified, intractable, and repugnant character failing. It was only after he stopped missing meetings regularly because of his discouragement and sense of futility that he discovered the part he played in his aloneness: that relationships do not inevitably wither. Instead, his previous relationships had been doomed by his choice to neglect them.

Some individuals internalize the group and repopulate their inner world. Years later, one client noted, “It’s as though my old group is sitting on my shoulder, watching me. I’m forever asking, What would the group say about this or that?” Often therapeutic changes persist and are consolidated because, even years later, the members don’t want to let the group down.29

Many of our clients have an impoverished history of social connection and have never felt valuable and integral to a group. For these individuals, a positive group experience may in itself be healing. Belonging in the group raises self-esteem and meets members’ dependency needs, but in ways that also foster responsibility and autonomy.30

Still, for some members, belonging can generate feelings of psychological regression: belonging can be frightening because it evokes fear of loss of self and of relinquishing personal autonomy.31 More typically, however, members of a therapy group come to mean a great deal to one another. The therapy group, at first perceived as an artificial construct that does not matter, may come to matter very much over time as members share their innermost thoughts. We have known groups whose members support one another through times of severe depression, through manic episodes, and through divorce, abortion, suicide, and sexual abuse, or even through the here-and-now feelings of betrayal within the group when two group members violate the group norms through a sexual encounter.

Even the most unlikely clients can form cohesive groups, as shown in a recent study of group therapy for marginalized intravenous drug users from the inner city with hepatitis C.32 We have seen a group actually carry one of its members to the hospital, and many groups mourning the death of a member. We have seen members of cancer support groups deliver eulogies at the funerals of other members. Relationships are often cemented by emotionally intense shared experiences. How many relationships in life are so richly layered?
Benefits of Group Cohesiveness: Evidence

Empirical evidence for the impact of group cohesiveness may not be as extensive or as systematic as research documenting the importance of relationship in individual psychotherapy, but is still very clear and relevant.33 Studying the effect of cohesiveness is more complex34 because it involves variables closely related to cohesion such as group climate (the degree of engagement, avoidance, and conflict in the group),35 therapist empathy,36 and alliance (the member-therapist relationship).37 The Group Questionnaire devised by Burlingame and colleagues synthesizes all these dimensions.38 The results of the research from all these perspectives, however, point to the same conclusion: Relationship is at the heart of effective group therapy.39

Group cohesion is no less important in the era of third-party oversight than it was in the past. In fact, the contemporary group therapist has an even larger responsibility to safeguard the therapeutic relationship in the face of imposed restrictions and intrusions from bureaucratic forces.40

We now turn to a broad overview of contemporary research and literature on cohesion. It highlights many of the approaches group researchers have used to evaluate and understand group cohesion and its clinical impact. (Readers who are less interested in research methodology and more interested in its direct clinical relevance may wish to proceed directly to the summary section.)

• In an early study of former group psychotherapy clients, investigators found that more than half considered mutual support the primary mode of help in group therapy. Clients who perceived their group as cohesive attended more sessions, experienced more social contact with other members, and felt that the group had been therapeutic. Improved clients were significantly more likely to have felt accepted by the other members and to mention particular individuals when queried about their group experience.41

• In 1970, I (IY) reported a study in which successful group therapy clients were asked to look back over their experience and to rate, in order of effectiveness, the series of therapeutic factors I describe in this book.42 Since that time, a vast number of studies using analogous designs have generated considerable dataon clients’ views of those aspects of group therapy that have been most useful. We will examine these results in depth in the next chapter; for now, it is sufficient to note that there is a strong consensus that clients regard group cohesiveness as an extremely important determinant of successful group therapy.

• In a six-month study of two long-term therapy groups, observers rated the process of each group session by scoring each member on five variables: acceptance, activity, sensitivity, abreaction (catharsis), and improvement.43 Weekly self-ratings were also obtained from each member. Both the research raters and group members considered “acceptance” to be the variable most strongly related to improvement.

• Similar conclusions were reached in a study of forty-seven clients in twelve psychotherapy groups. Members’ self-perceived personality change correlated significantly with both their feelings of involvement in the group and their assessment of total group cohesiveness.44

• My colleagues and I (IY) evaluated the one-year outcome of all forty clients who had started therapy in five outpatient groups.45 Outcome was then correlated with variables measured in the first three months of therapy. Positive outcome in therapy significantly correlated with only two predictor variables: group cohesiveness and general popularity—that is, clients who, early in the course of therapy, were most attracted to the group (high cohesiveness), and who were rated as more popular by the other group members at the sixth and twelfth weeks, had a better therapy outcome at the fiftieth week.46 The popularity finding, which in this study correlated even more positively with outcome than cohesiveness did, is, as we shall discuss shortly, relevant to group cohesiveness and sheds light on the mechanism through which group cohesiveness mediates change.

• The same findings emerge in more structured groups. A study of fifty-one clients who attended ten sessions of behavioral group therapy demonstrated that “attraction to the group” correlated significantly with improved self-esteem and inversely correlated with the group dropout rate.47

• The quality of intermember relationships has also been well documented as an essential ingredient in experiential groups intended to teach participants about group dynamics, such as T-groups and process groups. A rigorously designed study found a significant relationship between the quality of intermember relationships and outcome in a T-group of eleven subjects who met twice a week for a total of sixty-four hours.48 The members who entered into the most two-person mutually therapeutic relationships showed the most improvement during the course of the group.49 Furthermore, the perceived relationship with the group leader was unrelated to the extent of change.

• My colleagues Morton Lieberman and Matthew Miles and I (IY) conducted a study of 210 subjects in eighteen encounter groups encompassing ten ideological schools that reflected the field at the time. (These were gestalt, transactional analysis, T-groups, Synanon, personal growth, Esalen, psychoanalytic, marathon, psychodrama, and encounter tape, a group led by tape-recorded instructions.)50 Cohesiveness was assessed in several ways and reliably correlated with outcome.51 The results indicated that attraction to the group is indeed a powerful determinant of outcome. All methods of determining cohesiveness demonstrated a positive correlation between cohesiveness and outcome. A member who experienced little sense of belonging or attraction to the group, even measured early in the course of the sessions, was unlikely to benefit from the group and, in fact, was likely to have a negative outcome. Furthermore, the groups with the higher overall levels of cohesiveness had a significantly better total outcome than groups with low cohesiveness.

• Another large study (N = 393) of experiential training groups yielded a strong relationship between affiliativeness (a construct that overlaps considerably with cohesion) and outcome.52

• Roy MacKenzie and Volker Tschuschke, studying twenty clients in long-term inpatient groups, differentiated members’ personal “emotional relatedness to the group” from their appraisal of “group work” as a whole. The individual’s personal sense of belonging correlated with future outcome, whereas the total group work scales did not.53

• Simon Budman and his colleagues developed a scale to measure cohesiveness via observations by trained raters of videotaped group sessions. They studied fifteen therapy groups and found greater reductions in psychiatric symptoms and improvement in self-esteem in the most cohesively functioning groups. Group cohesion that was evident early—within the first thirty minutes of each session—predicted better outcomes.54

• A number of other studies have examined the role of the relationship between the client and the group leader in group therapy. Elsa Marziali and colleagues examined group cohesion and the client–group leader relationship in a highly structured thirty-session manualized interpersonal therapy group of clients with borderline personality disorder.55 Cohesion and member-leader relationship correlated strongly, supporting Budman’s findings, and both positively correlated with outcome.56 However, the member–group leader relationship measure was a more powerful predictor of outcome. The relationship between client and therapist may be particularly important for clients who are vulnerable or who have volatile interpersonal relationships, because for them the therapist serves an important containing and supportive function.

• Anthony Joyce and colleagues explored the experience of clients treated in brief group therapy for complicated loss and bereavement. They reported that the client’s strength of alliance to the therapist predicted a better outcome and showed a higher correlation with outcome than did group cohesion. This underscores the importance of looking at the individual client’s experience and not only the group’s cohesiveness, particularly in brief groups where an early positive start is essential.57

• Group therapy outcomes for social phobia were significantly better at both the end of treatment and at follow-up when clients reported higher engagement scores on the Group Climate Questionnaire developed by K. R. MacKenzie. Higher avoidance scores, in contrast, correlated with greater client distress. High conflict was also problematic and may be a sign of group trouble, rather than a necessary phase of group development that group leaders should casually accept.58
In a study of a short-term, structured, cognitive-behavioral therapy group for social phobia, the relationship with the therapist deepened over the twelve weeks of treatment and correlated positively with outcome, but group cohesion was static and not related to outcome.59 In this study the group was a setting for therapy and not an agent of therapy. Intermember bonds were not cultivated by the study therapists, leading the authors to conclude that in highly structured groups, what might matter most is the client-therapist collaboration around the therapy tasks.60

• A study of thirty-four clients with depression and social isolation treated in a twelve-session interactional problem-solving group reported that clients who described experiencing warmth and positive regard from the group leader had better therapy outcomes. The opposite also held true. Negative therapy outcomes were associated with negative client–group leader relationships. This correlative study does not address cause and effect, however: Are clients better liked by their therapist because they do well in therapy, or does being well liked promote more effort and a greater sense of well-being?61

• A study on inpatient group therapy for the treatment of PTSD in active military personnel demonstrated the significant contribution of group cohesion in effective outcomes. Group cohesion contributed a remarkable 50 percent of the variance to the outcome, and each soldier’s capacity and willingness to work with others in the group was a significant and unique predictor of outcome.62

• Evaluation of outcomes in brief intensive American Group Psychotherapy Association Institute training groups were influenced by higher levels of engagement.63 Positive outcomes may well be mediated by group engagement that fosters more interpersonal communication and self-disclosure.64

• Similar findings were reported in intensive experiential group training for 170 psychiatry residents who ranked group cohesion very highly in promoting openness to self-disclosure and feedback.65

• There is good evidence that individual attachment style also influences the relationship between cohesion and outcome. Individuals with anxious attachment who seek security benefit from group cohesion; but group members with a dismissive and avoidant attachment style may reject the strong pull to join and may need to be supported to work in the group at a pace tailored to them.66
A study of 327 group members treated in intensive inpatient programs that centered on psychodynamic groups meeting twice weekly for twelve weeks showed a significant correlation between group cohesion and outcome but with some variations. Interpersonal style also impacts the cohesion-outcome relationship. Group cohesion was of particular importance for members who had a cold and controlling interpersonal style and were harder to engage than more submissive group members.67

• Fit matters! A large body of research underscores this. The more the individual’s sense of engagement with the group aligns with the engagement level of the group as a whole, the stronger the relationship between engagement and outcome.68 Fit is also influenced by cultural norms. Western attitudes toward authority, emotional expression, self-disclosure, and individualism may contrast with other traditions.69

• Studies also show that group leaders tend to overestimate the degree of cohesion in their groups and their clients’ attraction and connection to their groups. Providing group leaders with ongoing feedback using measures such as the Group Questionnaire by the Burlingame team or the Group Session Rating Scale by Barry Duncan and Scott Miller alerts the therapist to members whose cohesion is failing or lagging. The alert provides an opportunity for early repair and is associated with improved outcomes.70

Cohesion-Outcome Relationship: Summary

Let’s summarize the key findings from the research literature about the cohesion-outcome relationship. Cohesion contributes significantly and consistently to outcome. This is true for both brief and longer-term (more than twenty sessions) group therapies and consistent across settings, client age, gender, and nature of client concerns. The cohesion-outcome relationship is most evident in groups of nine or fewer members and does not hold up as well with larger groups. The correlation is most prominent in groups that are interactional, but it is still relevant even in highly structured groups. The client’s attachment and interpersonal style make a difference in the cohesion-outcome relationship. Attending to culture, gender, sexual orientation, and ethnicity enhances the therapist’s capacity to build relationships within the group.

Group members deeply value the acceptance and support they receive from their therapy group. Therapy outcome is positively correlated with attraction to the group and with group popularity, a variable closely related to group support and acceptance. Individuals with positive outcomes have had more mutually satisfying relationships with other members. Emotional connectedness, self-disclosure, and the experience of group effectiveness all contribute to group cohesiveness. The presence of cohesion in the early sessions of the group correlates with positive outcomes. It is critical that leaders quickly address problems with cohesion and be alert to each member’s personal experience of the group. Group leaders tend to overestimate the strength of connection and engagement within their groups. Cohesion requires the therapist’s diligent attention to the dynamic interplay of member and group, and regular feedback about the state of the group and its members can help focus this attention, alerting the group leader to threats to group cohesion in the interest of timely therapist responsiveness.

For some clients and some groups (especially highly structured groups), the relationship with the leader may be the essential factor. A strong therapeutic relationship may not guarantee a positive outcome, but a poor therapeutic relationship will certainly not result in an effective treatment.

A host of studies demonstrate that group cohesiveness results in better group attendance, greater member participation, greater influenceability of members, and many other effects. We will consider these findings in detail shortly, as we discuss the mechanism by which cohesiveness fosters therapeutic change.

THE FOLLOWING CLINICAL EXAMPLE ILLUSTRATES THE IMPORTANCE of attending to members’ different reactions to the experience of group cohesion:

> Karen, a thirty-five-year-old college professor, sought group therapy to improve her interpersonal interactions with her students. Though she was a highly effective teacher and always received outstanding teaching evaluations, she resented her students, whom she experienced as intrusive and cloying. She said, “After my class I can scarcely wait to get back to my office and I waste no time putting the ‘Do Not Disturb’ sign on my door.”

Her personal life was not dissimilar: she sought solitude. Though she had once been married for five years, she and her husband had never consummated their marriage. Karen resisted intimate engagement at every point. Relationships threatened her: she felt they diminished her autonomy and personhood.

Upon beginning the group, she made it clear she had no interest in getting closer to others: instead her goal was to learn how to manage and tolerate people. She had little doubt that her disinterest in forming more intimate attachments emanated from her lifelong relationship with her intensely controlling and devaluing mother, who had imposed her will on every decision Karen had made in her life. It was impossible to be close to her mother, but also impossible, Karen felt, to resist her mother’s relentless demands and attempts to control her.

Karen had been in the group for several months when two new members joined the group. One of the new members, Joe, a middle-aged man, was eager to reduce his chronic feelings of isolation and alienation and immediately tried to draw close to the group members. Shortly after beginning the group he asked Karen about her personal life. Was she married? In a relationship?

Karen snapped at him, “Do not ever ask me personal questions about myself. I do not want to talk about that, least of all with someone I do not know.”

Taken aback, Joe looked at me (ML) imploringly. He said, “I thought we were here to get to know one another and to develop more openness. I’m confused. How does this group operate?”

Another member, who had known Karen since the group started, spoke to her directly, saying, “I know you’re not comfortable sharing much of yourself, but Joe is just trying to get to know all of us here. If you are so committed to not sharing or talking with us, how do you expect to make use of the group?”

I was very aware of how Karen’s defensiveness and rigidity would confound the new member and undermine the establishment of vital group norms, such as self-disclosure and feedback. I grew even more concerned when Karen responded to the question by saying, in part, “I am not going to be one of Molyn’s trained monkeys, responding to every overture with complete submission to the request.”

The “trained monkey” comment felt like a further attack on group cohesion, on group norms, and on me. Angry and protective of my group, I was sorely tempted to respond, “Yes, Karen, why are you here if you refuse to engage?” Fortunately, I caught myself. That comment would have been toxic and might well have driven Karen from the group.
Instead, I said, “I am perplexed by the intensity of your reaction, Karen. It makes me wonder what is going on for you right now in the group. There is an awful lot of heat here.”

She responded, “I thought I made it clear in my first session that I was here to learn to tolerate others, not to be grilled by them.”

“This takes me back to our first talk, Karen, when you described your relationship with your mother who so much imposed her will on you. You made it clear to us at your first meeting that you were very sensitive to pressure and you would never again submit to anyone’s will. It seems to me that the group has respected that and never inquired into painful issues in your life but accepted you and patiently waited for you to take the lead in sharing what you felt ready to say. Am I right?”

“Yes, until today. Until Joe. I’m not in the mood to be grilled about anything by anyone here.”

I turned to the new member and said, “Joe, what’s this like for you?”

“Oh,” said Joe, turning to Karen. “I’m new to this. I am so sorry. I was sweating and feeling very uncomfortable and just trying to be a member here. I am so clumsy: the last thing I wanted to do was make you feel bad.”

Karen looked away, dabbed her eyes, and gestured that it was time to change the subject.

This was a memorable session for Karen, and later in the course of therapy she referred to it as a vital learning experience. She realized no one wanted her to be a trained monkey and that she could be in the group right now, participate at her own pace, and address her anxiety about having to expose herself instantly to new members. << An interesting postscript: Karen stayed in the group for three years as an engaged and valued group member. Several years later, I received a referral to see her current husband. They had two children, and she had strongly suggested he pursue group therapy to address feelings of depression and social avoidance. She had been pressing him for more emotional engagement. MECHANISM OF ACTION How do group acceptance and trust help troubled individuals? Surely there must be more to it than simple support or acceptance; therapists learn early in their careers that love is not enough. Although the quality of the therapist-client relationship is crucial, the therapist must do more than simply relate warmly and honestly to the client.71 The therapeutic relationship creates favorable conditions for setting other processes in motion. What other processes? And how are they important? Carl Rogers’s deep insights into the therapeutic relationship and the centrality of therapist empathy, genuineness, and unconditional positive regard are as relevant today as they were nearly seventy years ago; indeed, these concepts have been heavily reinforced by contemporary research. Let us start our investigation by examining his views about the mode of action of the therapeutic relationship in individual therapy.72 In his most systematic description of the process of therapy, Rogers stated that when the conditions of an ideal therapist-client relationship exist, the following characteristic process is set into motion: 1. The client is increasingly free in expressing his feelings. 2. He begins to test reality and to become more discriminatory in his feelings and perceptions of his environment, his self, other persons, and his experiences. 3. He increasingly becomes aware of the incongruity between his experiences and his concept of self. 4. He also becomes aware of feelings that have been previously denied or distorted in awareness. 5. His concept of self, which now includes previously distorted or denied aspects, becomes more congruent with his experience. 6. He becomes increasingly able to experience, without threat, the therapist’s unconditional positive regard and to feel an unconditional positive self-regard. 7. He increasingly experiences himself as the focus of evaluation of the nature and worth of an object or experience. 8. He reacts to experience less in terms of his perception of others’ evaluation of him and more in terms of its effectiveness in enhancing his own development.73 A 2017 research review confirmed these principles by examining the experiential depth in therapy reported by four hundred clients in a range of psychotherapies who completed the Client Experiencing Scale, a seven-point scale based largely on Carl Rogers’s work. The study determined that there was a significant correlation between positive outcome and client depth of experiencing.74 Experiential depth is required to gain meaning, and it is most likely to arise within a strong therapeutic relationship.75 The therapist does not have to inspirit clients with the wish for growth (as if we could!). Instead, our task is to remove the obstacles that block the process of growth. And one way we do this is by creating an ideal therapeutic atmosphere in the therapy group. A strong bond between members not only disconfirms the client’s feelings of unworthiness but also encourages client self-disclosure and interpersonal risk-taking. These changes help deactivate old, negative beliefs about the self.76 There is experimental evidence that good rapport—a strong alliance, therapist empathy, and alignment about expectations—in individual therapy, and its equivalent, cohesiveness, in group therapy, encourage client self-reflection. Although it is the client’s experience that matters most, it is the therapist’s actions and behaviors that most contribute to the formation of the alliance.77 High cohesion is closely related to high degrees of intimacy, risk-taking, empathic listening, and feedback. The group members’ recognition that their group is working well at the task of interpersonal learning produces greater cohesion in a positive and self-reinforcing loop.78 Success with the group task strengthens the emotional bonds within the group. Perhaps cohesion is vital because many of our clients have not had the benefit of ongoing solid peer acceptance either in childhood or in their adult lives. One new member of a group, Ann, disclosed that she dreaded her job as a teacher; though she loved the students, her relationships with colleagues were consistently tense and hostile. Individual therapy had helped little with that, but what emerged quickly in the group was her intense need to always be right, often in ways that others experienced as demeaning and self-righteous. Group members readily saw both the problematic interpersonal behavior and the resultant pain she experienced. She received clear and direct feedback about her impact on others that she was able to hear and use quickly within the group as well as outside of it. Group members find validation by others to be a new and vital experience. Furthermore, acceptance and understanding among members may carry greater power and meaning than acceptance by a therapist. Other group members, after all, do not have to care or understand. They’re not paid for it; it’s not their “job.”79 We can also think of the power of group cohesion through the lens of current research on attachment and interpersonal neurobiology. A cohesive group offers its members a secure base for attachment that promotes emotional safety and the willingness to explore and take risks. The members have a safe haven that welcomes them.80 A cohesive group lowers members’ fear of rejection, shame, and rebuke. This promotes more interaction and tolerance for the emotional arousal required for effective therapy.81 Our connectedness plays a key role in helping us manage emotional distress. Humans emotionally regulate one another through their presence, validation, and empathic responsiveness.82 The intimacy developed in a group may be seen as a counterforce in a technologically driven culture that, in all ways—socially, professionally, recreationally—inexorably dehumanizes our relationships. It substitutes a social media preoccupation and virtual relationships for real person-to-person contact. Witness the soaring rates of depression and social isolation in the generation of youth growing up with their ever-present smartphones, which many prefer to actual human contact.83 Who has not observed a restaurant scenario in which each person is engaged with a device rather than with other people? The therapy group is a rare device-free zone in which direct human contact is expected and reinforced. (But we must also recognize the value of these devices in facilitating group therapy that meets by online video-teleconference, as we discuss in Chapter 14.) In a world in which traditional boundaries and structures that maintain relationships are increasingly permeable and transient, there is a greater need than ever for group belonging and group identity. Our contemporary world offers the illusion of connection that too often jeopardizes real connection. For group members, acceptance of self and acceptance of other members are interdependent: not only is self-acceptance basically dependent on acceptance by others, but acceptance of others is fully possible only after one can accept oneself. This principle is supported by both clinical research and wisdom.84 Members of a therapy group may at first experience considerable self-contempt and contempt for others. A manifestation of this feeling may be seen in the client’s initial refusal to join “a group of nuts,” or reluctance to become closely involved with a group of pained individuals for fear of being sucked into a maelstrom of misery. A particularly evocative response to the prospect of group therapy was given by a man in his eighties when he was invited to join a group for depressed elderly men: it was useless, he said, to waste time watering a bunch of dead trees—his metaphor for the other men in his nursing home.85 In our experience, most individuals seeking assistance from a mental health professional have in common two paramount difficulties: (1) establishing and maintaining meaningful interpersonal relationships, and (2) maintaining a sense of personal worth (self-esteem). It is hard to discuss these two interdependent areas as separate entities, but since in the preceding chapter we dwelled more heavily on the establishment of interpersonal relationships, we shall now turn briefly to self-esteem. Self-esteem refers to an individual’s evaluation of what he or she is really worth and is indissolubly linked to that person’s experiences in prior intimate relationships. Recall Harry Stack Sullivan’s statement: “The self may be said to be made up of reflected appraisals.”86 In other words, during early development, one’s perceptions of the attitudes of others toward oneself come to determine how one regards and values oneself. The individual internalizes many of these perceptions, and if they are consistent and congruent, relies on these internalized evaluations for some stable measure of self-worth. But, in addition to this internal reservoir of self-worth, people are, to a greater or lesser degree, always influenced by the evaluations of others—especially the evaluation provided by their fellow group members. Social psychology research supports this clinical understanding: the groups and relationships in which we take part become incorporated into the self.87 One’s attachment to a group is multidimensional. It is shaped both by the member’s degree of confidence in his attractiveness to the group—am I a desirable member?—and the member’s relative aspiration for affiliation—do I want to belong? Our identification with our groups plays a central role in our sense of belonging and identity.88 The influence of the group’s evaluation of an individual depends on several factors: how important the person feels the group to be; the frequency and specificity of the group’s communications to the person about that public esteem; and the salience to the person of the traits in question. In other words, the more the group matters to the person, and the more that person subscribes to the group values, the more he or she will be inclined to value the group judgment.89 Let us suppose that the group’s evaluation of the individual is less than the individual’s self-evaluation. How does the individual resolve that discrepancy? One recourse is to deny or distort the group’s evaluation. In a therapy group, this is not a positive development, for a vicious cycle is generated: the group evaluates the member poorly because he or she fails to participate in the group task (that is, active exploration of one’s self and one’s relationships with others). Any increase in defensiveness only further lowers the group’s esteem of that particular member. A common method used by members to resolve such a discrepancy is to devalue the group—emphasizing, for example, that the group is artificial or composed of disturbed individuals, and then comparing it unfavorably to some anchor group (for example, a social or occupational group) whose evaluation of the member is different. Members who take this path usually drop out of the group. Toward the end of a successful course of group therapy, one group member reviewed her early recollections of the group as follows: “For the longest time I told myself you were all nuts and your feedback to me about my defensiveness and inaccessibility was ridiculous. I wanted to quit—I’ve done that before many times, but I felt enough of a connection here to decide to stay. Once I made that choice, I started to tell myself that you cannot all be wrong about me. That was the turning point in my therapy.” This result is more likely if the individual is highly attracted to the group and if the public esteem is not too much lower than the self-esteem. But is the use of group pressure to change individual behavior or attitudes a form of social engineering? Is it not mechanical? Indeed, group therapy does employ behavioral principles; psychotherapy is, in all its variants, basically a form of learning. Even the most nondirective therapists use, at an unconscious level, operant conditioning techniques: they signal desirable conduct or attitudes to clients, whether explicitly or subtly, and in so doing create greater awareness of the relationship between interpersonal cause and effect.90 Behavioral and attitudinal change, regardless of origin, begets other changes. When a group evaluates a member more positively, the member feels more self-satisfied in the group and with the group itself, and the adaptive spiral described in the previous chapter is initiated. When a group’s evaluation of a member is higher than the member’s self-evaluation (a common experience), the member is placed in a state of dissonance and will attempt to resolve the discrepancy. What can a member in that position do? Perhaps the person will attempt to lower the public esteem by revealing personal inadequacies. However, in therapy groups, this behavior has the paradoxical effect of raising public esteem; disclosure of inadequacies is a valued group norm and enhances acceptance by the group. Another possible scenario, desirable therapeutically, occurs when group members reexamine and alter their low level of self-esteem. An illustrative clinical vignette will flesh out this formulation: > Maryetta, a thirty-four-year-old housewife with an emotionally impoverished background, sought therapy because of anxiety and guilt stemming from a series of extramarital affairs. Her self-esteem was exceedingly low; nothing escaped her self-excoriation: her physical appearance, her intelligence, her speech, her lack of imagination both as a mother and a wife. Although she received solace from her religious affiliation, it was a mixed blessing, because she felt too unworthy to socialize with the church folks in her community. She married a man she considered unappealing but nonetheless a good man—certainly good enough for her. Only during sex, particularly with several men at once, did she seem to come alive—to feel attractive, desirable, and able to give something of herself that seemed of value to others. However, this behavior clashed with her religious convictions and resulted in considerable anxiety and further self-derogation.

Viewing the group as a social microcosm, the therapist soon noted characteristic trends in Maryetta’s group behavior. She spoke often of the guilt issuing from her sexual behavior, and for many hours the group struggled with all the titillating ramifications of her predicament. At all other times in the group, however, she disengaged and offered nothing. She related to the group as she did to her social environment. She could belong to it, but she could not really relate to the other people: the only thing of real interest she felt she could offer was her genitals.

Over time in the group she began to respond and to question others and to offer warmth, support, and feedback. She began disclosing other, nonsexual, aspects of herself and soon found herself increasingly valued by the other members. She gradually disconfirmed her belief that she had little of value to offer and soon she was forced to entertain a more realistic and positive view of herself. Gradually, an adaptive spiral ensued: she began to establish meaningful nonsexual relationships both in and out of the group, and these, in turn, further enhanced her self-esteem. << Self-Esteem, Public Esteem, and Therapeutic Change: Evidence Group therapy research has not specifically investigated the relationship between public esteem and shifts in self-esteem. However, an interesting finding from a study of experiential groups was that members’ self-esteem decreased when public esteem decreased.91 (Public esteem is measured by sociometric data, which involves asking members to rank-order one another on several variables.) Researchers also discovered that the more a group member underestimated his or her public esteem, the more acceptable that member was to the other members. In other words, the ability to face one’s deficiencies, or even to judge oneself a little harshly, increases one’s public esteem. Humility, within limits, is far more adaptive than arrogance. It is also interesting to consider data on group popularity, a variable closely related to public esteem. The group members considered most popular by other members after six and twelve weeks of therapy had significantly better therapy outcomes than the other members at the end of one year.92 Thus, it seems that clients who have high public esteem early in the course of a group are destined to have a better therapy outcome. What factors foster popularity in therapy groups? Two variables, which did not themselves correlate with outcome, correlated significantly with popularity: 1. Previous self-disclosure.93 2. Interpersonal compatibility, which occurs when there are (perhaps fortuitously) individuals whose interpersonal needs happen to blend well with those of other group members.94 The most unpopular group members were rigid, moralistic, nonintrospective, and least involved in the group task. Some were rigidly at cross purposes with the group, attacking the group and isolating themselves. Some schizoid members were frightened of the group process and remained peripheral. A study of sixty-six group therapy members concluded, unsurprisingly, that less popular members were more inclined to drop out of the group.95 Social psychology research adds to our understanding of popularity and status in the group. The personality dimension of extraversion (assessed by a questionnaire, the NEO-PI96) predicts popularity. Popularity and influence in the group accrue to members by virtue of their active participation, self-disclosure, self-exploration, emotional expression, nondefensiveness, leadership, interest in others, and support of the group. Members who adhere most closely to group norms attain popularity and are more apt to change in therapy.97 It is important to note that the individual who adheres to the group norms not only is rewarded by increased public esteem within the group but also uses those same social skills to deal more effectively with interpersonal problems outside the group. Thus, increased popularity in the group acts therapeutically in two ways: by augmenting self-esteem and by reinforcing adaptive social skills. When an individual engages this sequence and acknowledges appreciation to the group for its help, it has an even more profound impact, as it elevates the esteem of the group as well. The rich get richer. The challenge in group therapy is helping the poor get richer as well. Group Cohesiveness and Group Attendance Continuation in the group is obviously a necessary prerequisite for successful treatment. Several studies indicate that clients who terminate early in the course of group therapy receive little benefit.98 In one study, over fifty clients who dropped out of long-term therapy groups within the first twelve meetings reported that they did so because of some stress encountered in the group. They were not satisfied with their therapy experience and they did not improve; indeed, many of these clients felt worse.99 However, those clients who remain in the group for at least several months have a high likelihood (85 percent in one study) of profiting from therapy.100 The relationship between cohesiveness and maintenance of membership has implications for the total group as well. Not only do the least cohesive members terminate membership and fail to benefit from therapy, but noncohesive groups with high member turnover prove to be less therapeutic for the remaining members as well. Clients who drop out challenge the group’s sense of worth and effectiveness and may generate a contagion phenomenon that can scuttle the group endeavor. Stability of membership is a necessary condition for effective short- and long-term interactional group therapy. Although most therapy groups go through an early phase of instability, during which some members drop out and replacements are added, the groups thereafter settle into a long, stable phase in which much of the solid work of therapy occurs. Some groups seem to enter this phase of stability early, and other groups never achieve it. In a group therapy follow-up study, clients often spontaneously underscored the importance of membership stability.101 In Chapter 15, we will discuss the issue of cohesiveness in groups led in clinical settings that preclude a stable long-term membership. For example, drop-in crisis groups or groups on an acute inpatient ward rarely have consistent membership even for two consecutive meetings. In these clinical situations, therapists must radically alter their perspectives on the life development of the group. We believe, for example, that we should consider the appropriate life span for the acute inpatient group to be a single session. Therapists must take significant responsibility for group cohesion by structuring and leading the group in a manner that offers help to as many members as possible during each session. Brief therapy groups pay a particularly high price for poor attendance, and therapists must make special efforts to increase cohesiveness early in the life of the group using specific strategies—including strong pregroup preparation, homogeneous composition, and structured interventions. Group Cohesiveness and the Expression of Hostility It would be a mistake to equate cohesiveness with comfort. Although cohesive groups may show greater acceptance, intimacy, and understanding, there is evidence that they also permit greater development and expression of hostility and conflict. Cohesive groups have norms (that is, unwritten rules of behavior accepted by group members) that encourage open expression of disagreement or conflict alongside support. In fact, unless hostility can be openly expressed, persistent covert hostile attitudes may hamper the development of cohesiveness and effective interpersonal learning. Unexpressed hostility simply smolders within, only to seep out in many indirect ways. It is not easy to continue communicating honestly with someone you dislike or even hate. The temptation to avoid the other and to break off communication is very great; yet when channels of communication are closed, so, too, are any hopes for conflict resolution and for personal growth.102 Group dynamics play an underappreciated role in societal conflict and reconciliation.ii Above all, communication must not be ruptured, and the adversaries must continue to work together in a meaningful way, take responsibility for their statements, and be willing to go beyond name-calling. This is, of course, a major difference between therapy groups and social groups, in which conflicts often result in the permanent rupture of relationships. As we explored in Chapter 2, clients’ descriptions of critical incidents in therapy often involve an episode in which they expressed strong negative affect. In each instance, however, the client was able to weather the storm and to continue relating (often in a more gratifying manner) to the other member. Underlying these events is the condition of cohesiveness. The group and the members must mean enough to each other to be willing to bear the discomfort of working through a conflict. Several studies demonstrate that cohesiveness is positively correlated with risk-taking and intensive interaction.103 Cohesiveness is not synonymous with love or with a continuous stream of supportive, positive statements; rather, cohesive groups are able to embrace conflict and to derive constructive benefit from it. Obviously, in times of conflict, scores on cohesiveness scales that emphasize warmth, comfort, and support will temporarily gyrate; thus, many researchers have reservations about viewing cohesiveness as a precise, stable, measurable, unidimensional variable and consider it instead as multidimensional.104 Measuring cohesion regularly, as noted earlier, can therefore be of great value to group leaders, alerting them to threats to cohesion or member alliance strains that might otherwise escape the therapist’s awareness.105 Keep in mind that it is the early engagement that later makes possible such successful working-through. The premature expression of excess hostility before group cohesion has been established is a leading cause of group fragmentation. It is important for clients to realize that their anger is not lethal. Both they and others can and do survive an expression of their impatience, irritability, and even outright rage. For some clients, it is also important to have the experience of weathering an attack. In the process, they may become better acquainted with the reasons for their feelings and beliefs and learn to withstand pressure from others.106 Conflict may also enhance self-disclosure, as each opponent tends to reveal more and more to clarify his or her position. If members are able to go beyond the mere statement of position, they may begin to understand the other’s experiential world, past and present, and begin to grasp that the other’s point of view may be as appropriate for that person as their own is for themselves. The working-through of extreme dislike or hatred of another person is an experience of great therapeutic power. The clinical situation described below demonstrates many of these points. (Another example may be found in my [IY] novel The Schopenhauer Cure and the video based on it.)107 > Two members of a therapy group—Susan, a forty-six-year-old very proper school principal, and Jean, a twenty-one-year-old high school dropout—became locked into a vicious struggle. Susan despised Jean because of her libertine lifestyle and what she imagined to be her sloth and promiscuity. Jean was enraged by Susan’s judgmental attitude, her sanctimoniousness, her dour sexlessness, and her closed posture to the world. Fortunately, both women were deeply committed members of the group. (Fortuitous circumstances played a part here. Jean had been a core member of the group for a year and then married and went abroad for three months. It was during Jean’s absence that Susan entered the group and became a very involved member.)

Both had had considerable past difficulty in tolerating and expressing anger. Over a four-month period, they interacted heavily, at times in pitched battles. For example, Susan erupted indignantly when she found out that Jean was obtaining food stamps illegally; and Jean, learning of Susan’s virginity, ventured the opinion that she was a curiosity, a museum piece, a mid-Victorian relic.

Much good group work was done because Jean and Susan, despite their conflict, never broke off communication. They learned a great deal about each other and eventually each realized the cruelty of their judgments of the other. Finally, they could both understand how much each meant to the other on both a personal and a symbolic level. Jean desperately wanted Susan’s approval; Susan deeply envied Jean for the freedom she had never permitted herself. In the working-through process, both fully experienced their rage, and both encountered and then accepted previously unknown parts of themselves. Ultimately, they developed an empathic understanding and then an acceptance of each other. Neither could possibly have tolerated the extreme discomfort of the conflict were it not for the strong cohesion that, despite the pain, bound them to the group. << Not only is group cohesiveness positively correlated with greater expression of hostility among group members, but there is also evidence that it is positively correlated with greater expression of hostility toward the leader.108 Regardless of the personal style or skill of group leaders, the therapy group will nonetheless come, often within the first dozen meetings, to experience some degree of resentment toward them (see Chapter 11 for a full discussion of this issue). Leaders do not fulfill members’ fantasized expectations, and, in the view of many members, do not care enough, do not direct enough, and do not offer immediate relief. If the members suppress these feelings of disappointment or anger, several harmful consequences may ensue. They may attack a convenient scapegoat—another member or some institution, like “psychiatry” or “therapy.” They may experience a smoldering anger within themselves or within the group as a whole. Such free-floating irritation may indicate that aggression is being displaced away from its more rightful source—often the therapist.109 Leaders who challenge rather than collude with group scapegoating not only safeguard against an unfair attack but also demonstrate their commitment to authenticity and responsibility in relationships. The group that is able to express negative feelings toward the therapist is almost invariably strengthened by the experience. It provides an important learning experience—namely, that one may express hostility directly without some ensuing irreparable calamity. It is far preferable that the therapist, the true object of the anger, be confronted than for the anger to be displaced onto some other member in the group. Furthermore, the therapist, let us hope, is far better able than a scapegoated member to withstand confrontation. The entire process is self-reinforcing: a concerted attack on the leader who handles it nondefensively serves to increase cohesiveness still further. A cautionary note about cohesion: misguided ideas about cohesion may interfere with the group task.110 Social psychologist Irving Janis coined the term “groupthink” to describe groups in which members reject critical thinking and feel compelled to share the same beliefs and emotions.111 Some groups are so invested in “supporting” their members that the members abandon genuine feedback and avoid all conflict. Effective group leaders need to endorse critical and analytic thought by the group members; it is always wise to respect the perspective of the dissonant voice.112 Authoritarian leaders discourage such thought, and their groups are less reflective, driven to premature certainty, and close down exploration prematurely.113 Group Cohesiveness and Other Therapy-Relevant Variables Research from both therapy and laboratory groups has demonstrated that group cohesiveness has a plethora of important consequences that have obvious relevance to the group therapeutic process.114 It has been shown, for example, that the members of a cohesive group, in contrast to the members of a noncohesive group, will: 1. Try harder to influence other group members115 2. Be more open to influence by the other members116 3. Be more willing to listen to others117 and more accepting of others118 4. Experience greater security and relief from tension in the group119 5. Participate more readily in meetings120 6. Self-disclose more121 7. Protect the group norms and exert more pressure on individuals deviating from the norms122 8. Be less susceptible to disruption as a group when a member terminates membership123 9. Experience greater ownership of the group therapy enterprise124 SUMMARY By definition, cohesiveness refers to the attraction that members have for their group and for the other members. It is experienced at interpersonal, intrapersonal, and intragroup levels. The members of a cohesive group are accepting of one another, supportive, and inclined to form meaningful relationships in the group. Cohesiveness is a significant factor in successful group therapy outcome. In conditions of acceptance and understanding, members will be more inclined to express and explore themselves, to become aware of and integrate hitherto unacceptable aspects of self, and to relate more deeply to others. Self-esteem is greatly influenced by the client’s role in a cohesive group. The social behavior required for members to be esteemed by the group is socially adaptive to the individual out of the group. In addition, highly cohesive groups are more stable groups, with better attendance and less turnover. This chapter presented evidence that such stability is vital to successful therapy, as early termination precludes benefit for the involved client and impedes the progress of the rest of the group as well. Cohesiveness favors self-disclosure, risk-taking, and the constructive expression of conflict in the group—phenomena that facilitate successful therapy. We will have much more to say in subsequent chapters about the therapist’s tasks and techniques in building group cohesion. Footnotes i The GQ is a thirty-item self-report that brings together the dimensions of group cohesion, group climate, the therapeutic alliance, and empathy into three scales—Positive Bond, Positive Work, and Negative Relationship—that together capture the entire group relationship experience of the group members. The GQ synthesizes two key dimensions of the group: relationship quality and relationship structure. The relationship quality aspect is the positive or negative component, and the relationship structure reflects whether the relationship at issue is member-member, member-leader, or member-group. The Positive Bond Scale captures member-member cohesion, member-leader alliance, and member-group climate. The Positive Work Scale captures member-member and member-leader tasks and goals. The Negative Relationship Scale captures member-member empathic failures, member-leader alliance ruptures, and member-group conflict. This comprehensive measure may well address previous problems with replicability of the measurement of cohesion and group relationships. See J. Krogel et al., “The Group Questionnaire: A Clinical and Empirically Derived Measure of Group Relationship,” Psychotherapy Research 23 (2013): 344–54. G. Burlingame, K. Whitcomb, S. Woodland, J. Olsen, M. Beecher, and R. Gleave, “The Effects of Relationship and Progress Feedback in Group Psychotherapy Using the GQ and OQ-45: A Randomized Clinical Trial,” Psychotherapy: Theory, Research and Practice 55 (2018): 116–31. ii This is as true on the mega-group level as on the interpersonal. We see echoes of it in our contemporary environment with the growth of tribalism and political nationalism. When this happens at the mega-group level, people often speak and listen only to those who espouse the same views and close themselves off to alternate ideas and perspectives. The drive to belong can create powerful feelings within groups. Members with a strong adherence to what is inside the group may experience strong pressure to exclude and devalue those outside the group. See G. Ofer, A Bridge over Troubled Water: Conflicts and Reconciliation in Groups and Society (London: Karnac Books, 2017). Chapters 7 The Therapist Transference and Transparency HAVING DISCUSSED THE MECHANISMS OF THERAPEUTIC CHANGE in group therapy, the tasks of the therapist, and the techniques by which the therapist accomplishes these tasks, we now turn from what the therapist must do in the group to how the therapist must be in the group. To what degree are you free to be yourself? How “honest” can you be? How do you utilize transparency and judicious self-disclosure effectively as a therapeutic tool? Any discussion of the group therapist’s scope and presence must begin with an examination of transference, which can be either an effective therapeutic tool or shackles that encumber your every movement. In his first and extraordinarily prescient essay on psychotherapy—the final chapter of Studies on Hysteria (1895)—Freud noted several possible impediments to the formation of a good working relationship between client and therapist.1 Most of them could be resolved easily, but one stemmed from deeper sources and resisted efforts to banish it from the therapeutic work. Freud labeled this impediment transference, since it consisted of attitudes toward the therapist that had been “transferred” from earlier attitudes toward important figures in the client’s life. These feelings toward the therapist were “false connections”—new editions of old impulses. Contemporary definitions of transference characterize it as a common relational phenomenon with both conscious and unconscious roots. Transference stems from the client’s fears, wishes, and developmental gaps. Today’s relationships are distorted by echoes of the past and reinforced by the client’s selective inattention to experiences that disconfirm these distortions.2 Group therapy adds the dimension of peer or horizontal transference to the more familiar vertical transference to the group leader.3 Freud soon realized that transference was far from an impediment to therapy; on the contrary, if used properly, it could be the therapist’s most effective tool.4 Many of today’s psychotherapeutic approaches, including cognitive therapy, acknowledge a concept similar to transference but may refer to it as the client’s “schema.”5 Contemporary psychodynamic psychotherapy suffuses the work of virtually all effective therapists. Effective therapists use the therapy relationship as a window into understanding and addressing the early, shaping influences and pathogenic beliefs that affect our clients.6 The ultimate objectives for the client are to: (1) reconfigure a new view of self; (2) establish a different relational experience with the therapist than with significant others in the past; and (3) translate that new understanding of self and other into a new narrative, new behavior, and adaptive function.7 We can see here the hallmarks of the corrective emotional experience described earlier. Hannah Levenson described it as the “gift that keeps on giving,” because it emancipates the client from the past and encourages continued growth and development even after therapy concludes.8 Considerable evolution in theory and technique has occurred in psychoanalysis and psychodynamic therapy over the past half century, with a powerful focus on the actual therapeutic relationship augmenting, but not discarding, the earlier focus on interpretation of transference. This focus emphasizes the therapist’s presence, emotional availability, and use of self in place of the opaque, emotionally aloof therapist.9 This is well captured by Stephen Mitchell: Many patients are now understood to be suffering not from conflictual infantile passions that can be tamed and transformed through reason and understanding but from stunted personal development. Deficiencies in caregiving in the earliest years are understood to have contributed to interfering with the emergence of a fully centered, integrated sense of self, of the patient’s own subjectivity. What the patient needs is not clarification or insight so much as a sustained experience of being seen, personally engaged, and, basically valued and cared about.10 Mitchell and many others argue that the “curative” factor in both individual and group therapy is the relationship, which requires the therapist’s authentic engagement and empathic attunement to the client’s internal emotional and subjective experience.11 Note that this new emphasis on the nature of the relationship means that psychotherapy has changed its focus from a one-person psychology (emphasizing the client’s pathology) to a two-person psychology (emphasizing mutual impact and shared responsibility for the relationship).12 In this model, the therapist’s emotional experience in the therapy is a relevant and powerful source of data about the client. How to make wise use of this data will be elaborated shortly when we discuss countertransference. Psychoanalysts and psychodynamic therapists have disagreed about the degree of permissible therapist disclosure—ranging from extensive disclosure to complete opaqueness.13 But they agree that transference is “inappropriate, intense, ambivalent, capricious, and tenacious,” and they also largely agree that transference, and well-timed, accurate, and empathic interpretation of transference, should be central to treatment.14 The difference between group therapists who consider the resolution of therapist-client transference as the paramount therapeutic factor and those who attach equal importance to the interpersonal learning that ensues from relationships between members and from other therapeutic factors is more than theoretical; in practice, they use markedly different techniques.15 Emphasizing the transference to the leader makes the group leader-centric and obscures attention to other group dynamics and group forces. Contemporary group therapy recognizes the value of focusing both on transference reactions to the group leader and to group peers.16 The following vignette from a session led by a traditional group analyst who made only therapist-related transference interpretations illustrates this point: > In one group session, two male members were absent, and four women members bitterly criticized the one male client present, who was gay, for his detachment and narcissism, which precluded any interest in the lives or problems of others. The therapist suggested that the women were attacking the male client because he did not desire them sexually, and that, moreover, he was not the real target; the women really wanted to attack the therapist for his refusal to engage them sexually. << The therapist selectively attended to the data and, from the vantage point of his particular conception of the paramount therapeutic factor—that is, transference resolution—made an interpretation that was technically correct, since it focused the members’ attention on their relationship with the leader. However, in our view, these therapist-centered interpretations are incomplete: they deny important intermember relationships. In fact, in this case, the male client had in fact been self-absorbed and detached from the other members of the group, and it was exceedingly important for him to recognize and understand his behavior. Any mandate that limits group therapists’ flexibility renders them less effective. This is a pitfall of ideological rigidity, which often arises as a compromised way for the therapist to manage clinical complexity.17 We have seen some therapists hobbled by a conviction that they must at all times remain totally anonymous and neutral, others by their crusade to be at all times totally “honest” and transparent, and still others by the dictum that they must make interpretations only of transference or only of mass group phenomena. The therapist’s approach to the group can amplify or moderate the expression of members’ transferences. If the therapist emphasizes his centrality, the group will become more regressive and dependent. In contrast, if the therapist values the peer interactions and peer transferences as primary expressions and not merely as displacements from the therapist, then the intensity of the transference experience in the group will be better modulated. Of course, the therapist has only limited vision of his or her own impact and how that influences the group’s process.18 In this chapter we make the following points about transference: • Transference does occur in therapy groups; indeed, it is omnipresent and radically influences the nature of the group discourse. • Without an appreciation of transference and its manifestations, the therapist will often not be able to understand fully the process of the group. • Therapists who ignore transference considerations may seriously misunderstand some transactions and confuse rather than guide the group members; therapists who attend only to the transference aspects of their relationships with members may fail to relate authentically to them. • There are clients whose therapy hinges on the resolution of transference distortion; there are others whose improvement will depend on interpersonal learning stemming from work not with the therapist but with another member, around such issues as competition, exploitation, or sexual and intimacy conflicts; and there are many clients who choose alternative therapeutic pathways in the group and derive their primary benefit from other therapeutic factors entirely. • Transference distortions between group members can be worked with as effectively, and perhaps even more effectively, than transference reactions to the therapist.19 • Attitudes toward the therapist are not all transference based: many are reality based. • By maintaining flexibility, you may make good therapeutic use of these irrational attitudes toward you without neglecting your many other functions in the group. TRANSFERENCE IN THE THERAPY GROUP Every client, to a greater or lesser degree, perceives the therapist incorrectly because of transference distortions, sometimes even before beginning therapy. One prominent psychiatrist tells the story of going out to meet a new client in the waiting room and having the client dispute that the therapist was who he said he was, because he was so physically different from the client’s imaginings of him.20 Few clients are entirely conflict free in their attitudes toward such issues as parental authority, dependency, God, autonomy, and rebellion—all of which are often personified in the person of the therapist. These distortions are continually at play under the surface of the group discourse. Indeed, hardly a meeting passes without some clear token of the powerful feelings evoked by the therapist. Witness the difference in the group when the therapist enters. Often the group may have been engaged in animated and lighthearted conversation only to lapse into heavy silence at the sight of the therapist. (Someone once said that the group therapy meeting officially begins when suddenly nothing happens!) The therapist’s arrival not only reminds the group of its task but may also evoke early constellations of feelings in each member about the adult, the teacher, the evaluator, and the apprehension about impending judgment and shame. Seating patterns often reveal some of the complex and powerful feelings toward the leader. Frequently, the members attempt to sit as far away from the leader as possible. As members filter into the meeting they usually occupy distant seats, leaving the seats on either side of the therapist as the penalty for late arrivals. A paranoid client often takes the seat directly opposite you, perhaps in order to watch you more closely; a dependent client generally sits close to you, often on your right. If co-therapists sit close to each other with only one vacant chair between them, you can bet it will be the last chair occupied. One member, after months of group therapy, still described a feeling of great oppression when seated between the therapists. (There is a practical reason, however, for co-therapists to sit apart, and that is so they can see one another’s reactions and nonverbal communication.) Over several years, for research purposes, I (IY) asked group members to fill out a questionnaire after each meeting. One of their tasks was to rank-order every member for activity (according to the total number of words each spoke). There was excellent intermember reliability in their ratings of the other group members, but exceedingly poor reliability in their ratings of the group therapist. In the same meetings some clients rated the therapist as the most active member, whereas others considered him the least active. The powerful and unrealistic feelings of the members toward the therapist prevented an accurate appraisal, even on this relatively objective dimension. One client, when asked to discuss his feelings toward me, stated that he disliked me greatly because I was cold and aloof. He reacted immediately to his disclosure with intense discomfort. He imagined possible repercussions: I might be too upset by his attack to be of any more help to the group; I might retaliate by kicking him out of the group; I might humiliate him by mocking him for some of the lurid sexual fantasies he had shared with the group; or I might use my psychiatric wizardry to harm him in the future. On another occasion many years ago, a group noted that I was wearing a copper bracelet. When they learned it was for tennis elbow, their reaction was extreme. They felt angry that I should be superstitious or ascribe credibility to any quack cures. (They had berated me for months for being too scientific and not human enough!) One member suggested that if I would spend more time with my clients and less time on the tennis court, everyone would be better off. One woman, who idealized me, said that she had seen copper bracelets advertised in a local magazine, but guessed that mine was more special—perhaps something I had bought in Switzerland. The following illustration underscores the scope of different responses to the same phenomena, rooted in different transferential reactions to the group leader: > I (ML) met with a therapy group two days after I had published a column about my father in a large circulation newspaper. He had passed away three months before, and I had been close to him. I was very pleased that I could tell his compelling story and heartened that it had been selected for publication in the paper’s prominent “Lives Lived” column.

The group knew of my father’s death because, when he died, I had explained to them why I would be missing two meetings. My announcement had not drawn much attention at the time, beyond some expressions of condolence. The publication of my column, however, provoked a variety of responses by group members.

At the start of the meeting, Karen, an often hostile and dismissive woman, angrily commented to me, “Have you not learned anything about keeping your private life private? It is inappropriate for you to share with the public, particularly your patients, this kind of personal detail about your father and your family. I do not want to see it, read it, or know this; you are imposing yourself on us.”

Sue, who was depressed and socially anxious, commented, “I wanted to express my condolences to you more fully when your father passed away, but I hesitated to do so, thinking that nothing I could offer would be meaningful or helpful to you. I want to express those condolences now—I don’t want to miss that opportunity twice.”

Bob, an older man recovering from alcohol addiction, commented, “I was pleased to read about your father and wished that I had grown up with a father like the man you had described. I felt sad for myself, but reading that column helped me understand you better and made me feel closer to you.“

Danny, an isolated, passive man, asked me, “How did you manage with your grief? How did the loss of your father affect you? My sorrow over my father’s death feels present every day of my life.”

Angry, self-absorbed Rob interjected, “Enough of this already—we are not here to talk about you, Molyn. I imagine you must be enjoying all the attention. We are here to talk about us, so let’s get to it.” << This vignette illustrates how the exact same stimulus can elicit many different transferential reactions. Here a broad gamut of them are on display, including the fear of getting close, the feeling of being undeserving of closeness, envy, admiration, and competitiveness with me for the group’s time and attention. What are other common manifestations of transference? Some members characteristically address all their remarks to the therapist, or speak to other members only to glance furtively at the therapist at the end of their statement. It is as though they speak to others in an attempt to reach the therapist, seeking the stamp of approval for all their thoughts and actions. They forget, as it were, their reasons for being in therapy, instead seeking continuously to gain conspiratorial eye contact; to be the last to leave the session; to be, in a multitude of ways, the therapist’s favorite child. Transference is so powerful and so ubiquitous that the dictum “the leader shall have no favorites” seems to be essential for the stability of every working group. In his early writings about groups, Freud suggested that group cohesiveness, curiously, derives from the universal wish to be the favorite of the leader and the mutual identifications the group members make with the idealized leader.21 Consider the prototypic human group: the sibling group. It is rife with intense rivalrous feelings: each child wishes to be the favorite and resents all rivals for their claims to parental love. The older child wishes to rob the younger of privileges or to eliminate the child altogether. And yet each realizes that the rival children are equally loved by their parents and that therefore one cannot destroy one’s siblings without incurring parental wrath and thus destroying oneself. There is only one possible solution: equality. If one cannot be the favorite, then there must be no favorite at all. Everyone is granted an equal investment in the leader, and out of this demand for equality is born what we have come to know as group spirit. Often, the group members do not wish to be equal to the leader. Quite the contrary: they have a thirst for obedience—a “lust for submission,” as Erich Fromm put it.22 We have regrettably often witnessed the marriage of weak, devitalized, and demoralized followers to charismatic, often malignantly narcissistic group leaders.23 It is one of the deep psychological forces in the current growth of populism and authoritarian leaders around the globe.24 The great writers also recognized this dynamic of followers and their leaders. To cite only one example, Tolstoy in the nineteenth century was keenly aware of the subtle intricacies of the member-leader relationship in the two most important groups of his day: the church and the military. His insight into the overvaluation of the leader gives War and Peace much of its pathos and richness. Consider Rostov’s regard for the Tsar: He was entirely absorbed in the feeling of happiness at the Tsar’s being near. His nearness alone made up to him by itself, he felt, for the loss of the whole day. He was happy, as a lover is happy when the moment of the longed-for meeting has come. Not daring to look around from the front line, by an ecstatic instance without looking around, he felt his approach.… Nearer and nearer moved this sun, as he seemed to Rostov, shedding around him rays of mild and majestic light, and now he felt himself enfolded in that radiance, he heard his voice—that voice caressing, calm, majestic, and yet so simple. And Rostov got up and went out to wander about among the campfires, dreaming of what happiness it would be to die—not saving the Emperor’s life (of that he did not dare to dream), but simply to die before the Emperor’s eyes. He really was in love with the Tsar and the glory of the Russian arms and the hope of coming victory. And he was not the only man who felt thus in those memorable days that preceded the battle of Austerlitz: nine-tenths of the men in the Russian army were at that moment in love, though less ecstatically, with their Tsar and the glory of the Russian arms.25 Indeed, it would seem that submersion in the love of a leader is a prerequisite for war. How ironic that more killing has probably been done under the aegis of love than of hatred! Napoleon, that consummate leader of men, was, according to Tolstoy, not ignorant of transference, nor did he hesitate to utilize it in the service of victory. In War and Peace, Tolstoy had him deliver this dispatch to his troops on the eve of battle: Soldiers! I will myself lead your battalions. I will keep out of fire, if you, with your habitual bravery, carry defeat and disorder into the ranks of the enemy. But if victory is for one moment doubtful, you will see your Emperor exposed to the enemy’s hottest attack, for there can be no uncertainty of victory, especially on this day, when it is a question of the honor of the French infantry, on which rests the honor of our nation.26 As a result of transference, the therapy group may impute special powers to the leaders to provide comfort, certainty, and refuge. Therapists’ words are often given more weight and wisdom than the words of others. Equally astute contributions made by other members are ignored or distorted. Group members believe that there are great, calculated depths to each of your interventions; that you predict and control all the events of the group. Even when you confess puzzlement or ignorance, this, too, is regarded as part of your clever technique, intended to have a particular effect on the group. Ah, to be the favorite child—of the parent, of the leader! For many group members, this longing serves as an internal horizon against which all other group events are silhouetted. However much each member cares for the other members of the group, however much each is pleased to see others work and receive help, there is a background of envy, of disappointment, that one is not basking alone in the light of the leader. The leader’s inquiries into these domains—who gets the most attention and who the least?—almost invariably plunge the members into a profitable examination of the group’s innards. > Daniela, new to the group, emailed me (ML) prior to her third meeting, noting she would be unavoidably late by ten minutes. She was still uncomfortable sitting in the chairs that faced the one-way mirror, behind which sat observers, and asked whether I could secure a chair for her with its back to the mirror? Email was clearly not the vehicle to address my dilemma of both wanting to support Daniela—and her early anxiety about self-exposure—and also wanting to explore the dynamic processes carried by her request. Would I look out for her? Could she make a special request? Did she warrant extra attention and care? What did it mean for her to ask? What did Daniela anticipate others would say in response to her request of the group leader?

I responded simply acknowledging her message and telling her that I looked forward to seeing her in the group and talking further. Daniela’s seemingly innocent request led to a rich exploration of sibling transferences, parental favoritism, competition for group and therapist attention and care, and my dilemma. At the end of the session Daniela stated that she learned a lot from the meeting, and joked that she could save herself a lot of stress by coming on time, while acknowledging, more seriously, that this was exactly the kind of work she needed to do. She had long wrestled with the apprehension of asking for care and recognition, and this seemingly simple request of the therapist opened up an important discussion of her deep longings. << Money often acts as a lightning rod for members’ feelings about the leader. The discussion of any hint of difference in fees—a sliding scale, perhaps—is particularly provocative and enlightening. How much one pays is often one of the group’s most tightly clutched secrets, since differing fees (and the silent, insidious corollary, different rights and different degrees of ownership) threaten the very foundation of the group: equality for all members. Are fees discussed in the group? Are bills covertly emailed? Handed out in each session? Is direct communication embraced or avoided? The therapist’s unease will foster the group’s unease and reduce the scope of group exploration. Therapists often feel awkward talking about money and fees, since it may open difficult issues such as the therapist’s income, perceived greed, entitlement, or members’ dependence, resentment, or dissatisfaction with the therapist.27 Members often expect the leader to sense their needs. One member wrote a list of major issues that troubled him and brought it to meeting after meeting, waiting for the therapist to divine its existence and ask him to read it. Obviously, the content of the list meant little—if he had really wanted to work on the problems enumerated there, he could have presented the list to the group himself. No, what was important was his belief in the therapist’s prescience. This member’s transference was such that he had incompletely differentiated himself from the therapist. Their ego boundaries were blurred; to know or feel something was, for him, tantamount to the therapist knowing and feeling it. When several members of a group share this desire for an all-knowing, all-caring leader, the meetings take on a characteristic flavor. The group seems helpless and dependent. The members deskill themselves and seem unable to help themselves or others. Deskilling is particularly dramatic in a group composed of professional therapists who suddenly seem unable to ask even the simplest questions of one another. They are all waiting—waiting for the touch of the therapist. No one wants to encourage anyone else to talk for fear of lessening his or her chance of obtaining the leader’s ministrations. Then, at other times or in other groups, the opposite occurs. Members challenge the leader continuously. The therapist is distrusted, misunderstood, treated like an enemy. Examples of such negative transference are common. One client, who had just joined a group, expended considerable energy in an effort to dominate the other members. Whenever the therapist attempted to point this out, the client regarded his intentions as malicious: the therapist was interfering with his growth; the therapist was threatened by him and was attempting to keep him subservient; or, finally, the therapist was deliberately blocking his progress, lest he improve too quickly and thus diminish the therapist’s income. Both of these positions in the extreme—idealization and devaluation—are destructive, anti-group-therapy norms. They represent resistance and regression in the group that demands attention before the norms concretize.28 In a group of adult female incest survivors, I (IY) was the only male in the group and was continually challenged. Unlike my female co-therapist, I could do nothing right. My appearance was attacked: I was too formal, too relaxed, too professional, not professional enough. Virtually every one of my interventions was met with criticism. My silence was labeled disinterest, and my support was viewed with suspicion. When I did not inquire deeply enough into the nature of their abuse, I was accused of lacking interest and empathy. When I did inquire, I was accused of being a voyeuristic deviant who was “getting off” by listening to stories of sexual violation. Though I had known that transferential anger from a group of women who were abuse victims would be inevitable, and also useful to the therapy process—and that the attacks were against my role rather than against me personally—the attacks were still difficult to tolerate, even to the point of destabilizing me. I began to dread each meeting and felt anxious, deskilled, and incompetent. The transference was not just being felt or spoken; it was being enacted powerfully.29 Not only was I attacked as a representative of the prototypical male in these group members’ lives, but I was also being “abused” in a form of role reversal: I was now the victim and they the perpetrators. This offered me a useful window on “knowing” the group members’ experience of being abused and helpless in the face of their abusers. Understanding the nature of transference and not retaliating with countertransference outrage was essential in retaining a therapeutic posture and avoiding another interactional cycle of victims and abusers.30 In another group, a member habitually became physically ill with flu symptoms whenever she grew depressed. The therapist could find no way to work with her without her feeling he was accusing her of malingering—a replay of the accusatory process in her relationships in her family. In yet another group, the therapist, on a couple of occasions, accepted a cough lozenge from a female member, and another member responded strongly, accusing him both of mooching and of exploiting the women in the group. Many irrational reasons exist for these attacks on the therapist, but some stem from the same feelings of helpless dependency that can also result in the worshipful obedience we have described. Some clients with a dismissive attachment style respond counterphobically to their vulnerability by incessantly defying the leader.31 Others validate their integrity or potency by attempting to triumph over the big adversary, feeling a sense of exhilaration and power from twisting the tail of the tiger and emerging unscathed. The most common charge members level against the leader is that of being too cold, too aloof, too inhuman. This charge has some basis in reality. For both professional and personal reasons, as we shall discuss shortly, many therapists do keep themselves hidden from the group. Also, their role as process commentator requires a certain distance from the group. But there is more to it. Although the members insist that they wish therapists to be more human, they have the simultaneous counter-wish that they be more than human (see The Schopenhauer Cure for a fictional portrayal of this phenomenon). Freud often made this observation. In The Future of an Illusion, he based his explanation for religious belief on the human being’s thirst for a superbeing.32 Freud believed that the integrity of groups depended on the existence of some superordinate figure who, as we discussed earlier, fosters the illusion of loving each member equally. Solid group bonds become chains of sand if the leader is lost. Hence, there is great ambivalence in the members’ directive to the leader to be “more human.” They complain that you tell them nothing of yourself, yet they rarely inquire explicitly. They demand that you be more human yet excoriate you if you wear a copper bracelet, accept a throat lozenge, or forget to tell the group that you have had an email exchange with a member. They prefer not to believe you if you profess puzzlement or ignorance. The illness or infirmity of a therapist always arouses considerable discomfort among the members, as though somehow the therapist should be beyond biological limitation. Groups can even collude to deny the reality of a beloved therapist’s evident decline.33 A group of psychiatry residents in a process group put the dilemma very clearly. They often discussed the “big people” out in the world: their therapists, team leaders, staff supervisors, and the adult community of senior practicing psychiatrists. The closer these residents came to completing their training, the more important and problematic the big people became. I (IY) wondered aloud whether they, too, might soon become “big people.” Could it be that even I had my own “big people”? There were two opposing sets of concerns about the “big people,” and they were equally troubling: first, that the “big people” were real, that they possessed superior wisdom and knowledge and would dispense an honest but terrible justice to the young, presumptuous frauds who tried to join their ranks; or, second, that the “big people” themselves were frauds, and the members were all Dorothys facing the Wizard of Oz. The second possibility had more frightening implications than the first: it brought them face to face with their intrinsic loneliness and apartness. It was as if, for a brief time, life’s illusions were stripped away, exposing the naked scaffolding of existence—a terrifying sight, one that we conceal from ourselves with the heaviest of curtains. The “big people” are one of our most effective curtains. As frightening as their judgment may be, it is far less terrible than that other alternative—that there are no “big people” and that one is finally and utterly alone. The leader is thus seen unrealistically by members for many reasons. True transference or displacement of affect from some prior relationship is one reason; conflicted attitudes toward authority (dependency, distrust, rebellion, counterdependency) that become personified in the therapist is another; what the leader evokes or provokes by virtue of his or her presence and style is yet another; and still another reason is the tendency to imbue therapists with great protective powers so as to use them as a shield against existential anxiety. An additional but entirely rational source of members’ strong feelings toward the group therapist lies in the members’ explicit or intuitive appreciation of the therapist’s great and real power. Group leaders’ presence and impartiality are, as we have already discussed, essential for group survival and stability; they have the power to expel members, add new members, and mobilize group pressure against anyone they wish. In fact, the sources of intense, irrational feelings toward the therapist are so varied and so powerful that transference will always occur. The therapist need not make any effort to generate or facilitate the development of transference. An illustrative example of transference developing in the presence of and despite therapist transparency occurred with a client who often attacked me (IY) for aloofness, deviousness, and hiddenness. He accused me of manipulation, of pulling strings to guide each member’s behavior, of not being clear and open, and of never really coming out and telling the group exactly what I was trying to do in therapy. Yet this man was a member of a group in which I had been writing very clear, honest, transparent group summaries and mailing them to the members before the next meeting. A more earnest attempt to demystify the therapeutic process would be difficult to imagine. When asked by some of the members about my self-disclosure in the summaries, he acknowledged that he had not read them—they remained unopened on his desk. Exploring the gap between the client’s and the therapist’s view of the same encounter provides rich learning opportunities. > In a second pregroup preparation meeting, I (ML) asked Ron, a middle-aged executive with chronic depression and a history of adversarial relationships, how he felt our first meeting had gone. Ron responded that he was very angry that I had presumed power over him and diminished him. He said he had come for a second meeting largely to voice his outrage.
I was stunned, expressed my concern and regret for generating that kind of reaction, and said I hoped we could explore what happened. Ron responded, “I offered you my permission to speak with my individual therapist who referred me to you. That was a big step for me in trusting you—and then you responded (here he mimicked a high-handed tone) ‘I don’t need your permission to speak with him.’ That pissed me off big time. Here I was offering you a gift of my trust and you were telling me you could do what you want anyways.”

I responded, “I am so sorry that you felt that, but I am very grateful that you have returned today to talk with me, rather than blowing this and me off. I did not mean to make you feel diminished. I am sorry that it felt like a power move on my part. What I had hoped to convey was that I assumed that permission was a component of the referral process and that as your group therapist I anticipated I would work collaboratively with your individual therapist in your interest. I want to understand what happened between us, and believe we can both learn from it.”

Ron accepted the apology, calmed considerably, and added, “Isn’t it funny how power became such a hot issue so quickly? That happens to me a lot.” << As long as a group therapist assumes the responsibility of leadership, transference will occur. We have never seen a group develop without a deep, complex underpinning of transference. The problem is thus not evocation but resolution of transference. The therapist who is to make therapeutic use of transference must help clients recognize, understand, and work through their distorted view of the leader. How does the group resolve transference distortions? Two major approaches are seen in therapy groups: consensual validation and increased therapist transparency. Consensual Validation The therapist may encourage a client to compare his or her impressions of the therapist with those of the other members. If many or all of the group members concur in the client’s view of and feelings toward the therapist, then it is clear that either the member’s reaction stems from global group forces related to the therapist’s role in the group or the reaction is not unrealistic at all—the group members are perceiving the therapist accurately. If, on the other hand, there is no consensus, if one member alone has a particular view of the therapist, then this member may be helped to examine the possibility that he or she sees the therapist, and perhaps other people too, through an internal distorting prism. In this process the therapist must take care to operate with a spirit of open inquiry and self-reflection, lest it turn into a process of majority rule or mobilizing the group members against a member. Also, remember: There can be truth even in the idiosyncratic reaction of a single member. The wise group leader pays careful heed to even the single dissonant voice. Increased Therapist Transparency The other major approach relies on the therapeutic use of the self. Therapists help clients confirm or disconfirm their impressions of them by gradually revealing more of themselves. The client is pressed to deal with the therapist as a real person in the here-and-now. Thus, you respond to the client, you share your feelings, you acknowledge or refute motives or feelings attributed to you, you look at your own blind spots, you demonstrate respect for the feedback the members offer you. In the face of this mounting real-life data, clients are impelled to examine the nature and the basis of their powerful distorted beliefs about the therapist. The group therapist undergoes a gradual metamorphosis during the life of the group. In the beginning you busy yourself with the many functions necessary in the creation of the group; with the development of a social system in which the many therapeutic factors may operate; and with the activation and illumination of the here-and-now. Gradually, as the group progresses, you begin to interact more personally with each of the members, and as you become more of a fleshed-out person, the members find it more difficult to maintain the early stereotypes they had projected onto you. Your disclosure about the client’s impact on you is a particularly effective intervention because it deepens understanding of the bidirectional impact between therapist and group member.34 This process between you and each of the members is not qualitatively different from the interpersonal learning taking place among the members. After all, you have no monopoly on authority, dominance, wisdom, or aloofness, and many of the members work out their conflicts in these areas not only with the therapist but also with other group members. Attention to the degree of transparency of the therapist is by no means limited to group therapy. However, the pace, the degree, and the nature of the therapist’s transparency, along with the relationship between this activity of the therapist and the therapist’s other tasks in the group, are problematic and deserve careful consideration. More than any other single characteristic, the nature and degree of therapist self-disclosure differentiate the various schools of group therapy. Judicious therapist self-disclosure is a defining characteristic of the interpersonal model of group psychotherapy.35 THE PSYCHOTHERAPIST AND TRANSPARENCY Psychotherapeutic innovations appear and vanish with bewildering rapidity.36 Only a truly intrepid observer would attempt to differentiate evanescent from potentially important and durable trends in the diffuse, heterodox American psychotherapeutic scene. Nevertheless, there is evidence, in widely varying settings, of a shift in therapists’ transparency with their clients. It matches the greater exposure and transparency in the world at large fostered by modern social media. Consider the following vignettes: > Students who have observed a therapy group through a one-way mirror reverse roles at the end of the meeting. Here, the clients are permitted to observe while the therapist and the students discuss or rehash the meeting. Or, in inpatient groups, the observers enter the room twenty minutes before the end of the session to discuss their observations of the meeting. In the final ten minutes, the group members react to the observers’ comments.37 << > At a university training center, a tutorial technique has been employed in which four psychiatric residents meet regularly with an experienced clinician who conducts an interview in front of a one-way mirror. The client is often invited to observe the post-interview discussion. << > Tom, one of two group co-therapists, began a meeting by addressing a client who had been extremely distressed at the previous meeting. He asked him how he was feeling and whether that session had been helpful to him. The co-therapist then said, “Tom, I think you’re doing just what I was doing a couple of weeks ago—pressing the clients to tell me how effective our therapy is. We both seem on a constant lookout for reassurance. I think we are reflecting some of the general discouragement in the group. I wonder whether the members may be feeling pressure that they have to improve to keep up our spirits.” << > In an ongoing group, a member reported to the group that she had seen a YouTube video of a lecture on group therapy and a group demonstration given by their group leader. She distributed the link to the group and wanted to discuss why the group leader was more relaxed and personable in the video than in their therapy group. What accounted for the difference? << Without discussing the merits or the disadvantages of the approaches demonstrated in these vignettes, it can be said that there is no evidence that these approaches corroded the therapeutic relationship or situation. In none of these situations did the group members lose faith in their all-too-human therapists. On the contrary, group members developed more faith in therapists who were willing to reveal their thinking. For example, the clients who observed their therapists disagree with one another learned that although no single true way exists, the therapists are nonetheless dedicated and committed to finding ways of helping their clients. In each of the vignettes, the therapists abandon their traditional role and share human uncertainties with their clients. Gradually the therapeutic process is demystified and becomes more collaborative. One study examined the reaction of therapy clients to sessions in which the therapist cried. This is a common experience: a recent survey reported such events in 70 percent of therapists across all models, age groups, and genders.38 What is the impact of such an event? Therapists believe it has a positive and humanizing effect on the therapeutic relationship. And the clients’ perspective? It depends! The therapist’s emotionality strengthens strong relationships and undermines weak ones.39 The reevaluation of the therapist’s role and authority is not just a modern phenomenon but a long-standing trend away from therapeutic detachment and toward therapeutic human engagement. There were adumbrations of this shift among the earliest dynamic therapists. For example, Sándor Ferenczi, a close associate of Freud’s who was dissatisfied with the therapeutic results of psychoanalysis, continually challenged the aloof, omniscient role of the classical psychoanalyst. Ferenczi and Freud in fact parted ways because of Ferenczi’s conviction that it was the tender, nonauthoritarian, mutual, honest, transparent relationship that therapist and client created together, not the rational interpretation, that was the mutative force of therapy.40 In his pioneering emphasis on the interpersonal relationship, Ferenczi influenced American psychotherapy through his impact on future leaders in the field such as William Alanson White, Harry Stack Sullivan, and Frieda Fromm-Reichman. Ferenczi also had a significant but overlooked role in the development of group therapy, underscoring the interpersonal base of many of the group therapeutic factors.41 During his last several years, he openly acknowledged his fallibility to clients and, in response to a just criticism, felt free to say, “I think you may have touched upon an area in which I am not entirely free myself. Perhaps you can help me see what’s wrong with me.”42 S. H. Foulkes, a British pioneer group therapist, stated more than eighty years ago that the mature group therapist was truly modest, one who could sincerely say to a group, “Here we are together facing reality and the basic problems of human existence. I am one of you, not more and not less.”43 I (IY) explore therapist transparency more fully in other literary forms: four books of stories based on my psychotherapy cases—Love’s Executioner, Momma and the Meaning of Life, Staring at the Sun, and Creatures of a Day—and three novels—When Nietzsche Wept, in which the client and therapist alternate roles; Lying on the Couch, with a therapist protagonist who reruns Ferenczi’s mutual analysis experiment by revealing himself fully to a client; and The Schopenhauer Cure, where the therapist engages in heroic transparency, sharing with the group members his mortal illness.44 After the publication of each of these books, I received a deluge of letters, from both clients and therapists, attesting to the widespread interest in and craving for a more human relationship in the therapy venture. Those therapists who attempt greater transparency argue that therapy is a rational, explicable process. They recognize that it is impossible not to be self-disclosing—what you wear, how you set up your office, what decorates your wall—all reveal aspects of who you are. So it makes sense to harness it for therapeutic benefit. As therapists gain experience, they inevitably become more transparent in their therapy.45 The more transparent therapists espouse a humanistic attitude to therapy, in which the client is considered a full collaborator in the therapeutic venture. No mystery need surround the therapist or the therapeutic procedure; aside from the ameliorative effects stemming from expectations of help from a magical being, there is little to be lost and much to be gained through the demystification of therapy. This helps align expectations and strengthens the therapeutic alliance.46 A therapy based on a true alliance between therapist and enlightened client reflects a greater respect for the capacities of the client and, with it, a greater reliance on the client’s self-awareness rather than on the easier but precarious comfort of reliance on the sage therapist. Greater therapist transparency is, in part, a reaction to the long tenure of the old authoritarian medical healer, who, for many centuries, has colluded with the distressed human being’s wish for succor from a superior being. Healers have harnessed, and indeed cultivated, this need as a powerful agent of treatment: Latin prescriptions, specialized language, secret institutes with lengthy and severe apprenticeships, imposing offices, and power displays of diplomas—all have contributed to the image of the healer as a powerful, mysterious, and prescient figure. In unlocking the shackles of this ancestral role, some overly disclosing therapists have at times sacrificed effectiveness on the altar of self-disclosure. However, the dangers of indiscriminate therapist transparency (which we shall consider shortly) should not deter us from exploring the judicious use of therapist self-disclosure. The Effect of Therapist Transparency on the Therapy Group The classic objection to therapist transparency emanates from the traditional analytic belief that the paramount therapeutic factor is the resolution of client-therapist transference. This view holds that the therapist must remain relatively anonymous or opaque in order to foster and unencumber the development of transference feelings toward him or her. It is our position, however, that other therapeutic factors are of equal or greater importance, and that the therapist who judiciously uses his or her own person increases the therapeutic power of the group by encouraging the development of these other group factors. In doing so, you gain considerable role flexibility and maneuverability and may contribute to shaping group norms (there is considerable research evidence that therapist self-disclosure facilitates greater openness between group members, as well as between family members in family therapy),47 and to here-and-now activation and process illumination. By decentralizing your position in the group, you also elevate the place of peer-to-peer transferences and hasten the development of group autonomy and cohesiveness. We see corroborating evidence from individual therapy: therapist self-disclosure is often experienced by clients as supportive and normalizing. It reduces distress and correlates with better outcome, and it fosters deeper exploration on the client’s part and strengthens the therapeutic relationship.48 Therapist self-disclosure is particularly effective when it serves to engage the client authentically, conveys therapeutic warmth, and does not serve to control or direct the therapeutic relationship.49 Therapist self-disclosure is not a “one-size-fits-all” action. It must be tailored to the client and guided by specific therapeutic intent. It includes both here-and-now interpersonal feedback, aimed at promoting change by illustrating the client’s interpersonal impact, and more general therapist self-disclosure that aims to humanize the relationship. We disclose to support and draw closer to the client. We are the agent of the self-disclosure, but it is always the client who is the focus.50 And though we encourage our clients to strike while their iron is hot, group leaders should wait for their irons to cool before disclosing to avoid the expression of unprocessed countertransference reactions.51 One objection to therapist self-disclosure is the fear of escalation—the fear that once you reveal yourself, the group will insatiably demand even more, and you will carom into all kinds of messy boundary situations. Recall that powerful forces in the group oppose this trend and that you are committed to self-disclosure for therapeutic purposes only and never for self-aggrandizement. The members are extraordinarily curious about you, yet at the same time wish you to remain unknown and powerful. Some of these points were apparent in a meeting many years ago when I (IY) had just begun to lead therapy groups. I had just returned from leading a week-long residential leadership training program T-group sponsored by the National Training Laboratory. Since greater leader transparency is the rule in such groups, I returned to my therapy group primed for greater self-revelation: > Four members—Don, Rolando, Janelle, and Martha—were present at the twenty-ninth meeting of the group. One member and my co-therapist were absent; one other member, Peter, had dropped out of the group at the previous meeting. The first theme that emerged was the group’s response to Peter’s termination. The group discussed this gingerly, from a great distance, and I commented that we had, it seemed to me, never honestly discussed our feelings about Peter when he was present, and that we were avoiding them now, even after his departure. Among the responses was Martha’s comment that she was glad he had left, that she had felt they couldn’t reach him, and that she didn’t feel it was worth it to try. She then commented on his lack of education and noted her surprise that he had even been included in the group—an oblique swipe at the therapists.

I felt the group had not only avoided discussing Peter but had also declined to confront Martha’s judgmental attitude and incessant criticism of others. I thought I might help Martha and the group explore this issue by asking her to go around the group and describe those aspects of each person she found herself unable to accept. This task proved very difficult for her, and she generally avoided it by phrasing her objections in the past tense, as in, “I once disliked some trait in you but now it’s different.” When she had finished with each of the members, I pointed out that she had left me out; indeed, she had never expressed her feelings toward me except through indirect attacks. She proceeded to compare me unfavorably with the co-therapist, stating that she found me too retiring and ineffectual; she then immediately attempted to undo the remarks by commenting that “Still waters run deep,” and recalling examples of my sensitivity to her.

The other members suddenly volunteered to tackle the same task and, in the process, revealed many long-term group secrets: Don’s passivity, Janelle’s sloppy and inappropriate attire, and Rolando’s lack of empathy with the women in the group. Martha was compared to a golf ball: “tightly wound up with an enamel cover.” I was attacked by Rolando for my deviousness and lack of interest in him.The members then asked me to go around the group in the same manner as they had done. Being fresh from a seven-day T-group and no admirer of generals who led their army from the rear, I took a deep breath and agreed. I told Martha that her quickness to judge and condemn others made me reluctant to show myself to her, lest I, too, be judged and found wanting. I agreed with the golf-ball metaphor and added that her inclination to be critical made it difficult for me to approach her, save as an expert technician. I told Don that I felt his gaze on me constantly; I knew he desperately wanted something from me, and that the intensity of his need and my inability to satisfy that need often made me very uncomfortable. I told Janelle that I missed a spirit of opposition in her; she tended to accept and exalt everything that I said so uncritically that it became difficult at times to relate to her as an autonomous adult.

The meeting continued at an intense, involved level, and at its end the observers expressed grave concerns about my behavior. They felt that I had irrevocably relinquished my leadership role and become a group member, that the group would never be the same, and that, furthermore, I was placing my co-therapist, who would return the following week, in an untenable position.

In fact, none of these predictions materialized. In subsequent meetings, the group plunged more deeply into work; several weeks were required to assimilate the material generated in that single meeting. My co-therapist and the other member who had missed the session were quickly able to catch up. In addition, the group members, following the model of the therapist, related to one another far more forthrightly than before and made no demands on me or my co-therapist for escalated self-disclosure. << There are many different types of therapist transparency, depending on the therapist’s personal style and the stage of the group. Therapists may self-disclose to facilitate transference resolution; to model therapeutic norms; to assist the interpersonal learning of the members who want to work on their relationship with the group leader; or to support and accept members by saying, in effect, “I value and respect you and demonstrate this by giving of myself.” But one’s aim must always be guided by the needs of the clients and the therapy and not by one’s personal needs. > An illustrative example of therapist disclosure that facilitated therapy occurred in a meeting when all three women members discussed their strong sexual attraction to me (IY). Much work was done on the transference aspects of the situation, on the women being attracted to a man who was obviously professionally off-limits and unattainable, older, in a position of authority, and so on. I then pointed out that there was another side to it. None of the women had expressed similar feelings toward my co-therapist (also male); furthermore, other female clients who had been in the group previously had had the same feelings. I could not deny that it gave me pleasure to hear these sentiments expressed, and I asked them to help me look at my blind spots: What was I doing unwittingly to encourage their positive response to me?

My request opened up a long and fruitful discussion of the group members’ feelings about both therapists. There was much agreement that the two of us were very different: I was vainer, took much more care about my physical appearance and clothes, and had an exactitude and preciseness about my statements that created about me an attractive aura of suaveness and confidence. The other therapist was sloppier in appearance and behavior; he spoke more often when he was unsure of what he was going to say; he took more risks and was willing to be wrong, and, in so doing, was more often helpful to the clients. The feedback sounded right to me. I had heard it before and told the group so. I thought about their comments during the week and, at the following meeting, thanked the group members and told them that they had been helpful to me. << Making errors is commonplace; it is what is done with the errors that is often critical in therapy. Our clients do not expect us to be perfect—but they do expect us to be honest and decent. One of the more common errors therapists make is to respond defensively and shirk responsibility for their errors, which tends to isolate and fault the client.52 We must expect and anticipate alliance strains and even alliance ruptures as part of the “tear and repair” process of therapy.53 The good news is that, once recognized, these strains can indeed be gainfully repaired, and, like a healing fractured bone, may even become stronger as a result of the repair. The correlation to better clinical outcomes is predictably robust.54 Therapists are not omniscient, and it is best to acknowledge that. > After an angry exchange between two members, Barbara and Mae, the group found it difficult to repair the damage Barbara had experienced. Although Barbara was eventually able to work through her differences with Mae, Barbara continued to struggle with how she had been left so unprotected by me (ML). Numerous attempts at explanation and understanding failed to break the impasse, until I stated, “I regret what happened very much. I have to acknowledge that Mae’s criticism of you took me by surprise—it hit like a tropical storm, and I was at a loss for words. It took me some time to regroup, but by then the damage had been done. If I knew then what I know now, I would have responded differently. I am sorry for that.”

Rather than feeling that I was not competent because I had missed something of great importance, Barbara felt relieved and said that what I’d said was exactly what she needed to hear. Barbara did not need me to be omnipotent—she wanted me to be human, to be able to acknowledge my error, and to learn from what had happened so that it would be less likely to occur in the future. << > Another illustrative clinical example occurred in the group of women survivors of sexual abuse described earlier in this chapter. The ongoing, withering anger toward me (IY, and, to a slightly lesser degree, toward my female co-therapist) had gotten to us, and toward the end of one meeting, we both openly discussed our experience in the group. I revealed that I felt demoralized and deskilled, that everything I tried in the group had failed to be helpful, and furthermore that I felt anxious and confused in the group. My co-leader discussed similar feelings: her discomfort about the competitive way the women related to her, and about the continual pressure placed on her to reveal any abuse that she may have experienced. We told them that their relentless anger and distrust of us was fully understandable in the light of their past abuse, but that, nonetheless, we both wanted to shriek, “These were terrible things that happened to you, but we didn’t do them.”

This episode proved to be a turning point for the group. There was still one member (who reported having undergone savage ritual abuse as a child) who continued in the same vein—“Oh, you’re uncomfortable and confused? What a shame! But at least now you know how it feels.” The others, however, were deeply affected by our admission. They were astounded to learn of our discomfort and of their power over us, and gratified that we were willing to relinquish authority and relate to them in an open, egalitarian fashion. From that point on, the group moved into a far more profitable work phase. << It was constructive for us to acknowledge and work with these feelings openly rather than simply allowing ourselves to be continually pummeled by the group. Our distress gave us a window into the experience of our clients, but simply to absorb it would have been destructive to us and to the clients. There is no healing in repetition alone without recognition and working through.55 Being so intensely devalued is unsettling to almost all therapists, especially in the public domain of the group. Yet it also creates a remarkable therapeutic opportunity if therapists can maintain their dignity and honestly address their experience in the group. Such confrontation is particularly challenging to the neophyte group therapist and underscores the value of supervision to sustain therapist perspective and equanimity.56 These clinical episodes illustrate some general principles that prove useful to the therapist when receiving feedback, especially negative feedback: • Take it seriously. Listen to it, consider it, and respond to it. Respect the clients and let their feedback matter to you; if you don’t, you merely increase their sense of frustration and impotence. • Do not respond defensively or fault the client. It is a grave error to pathologize the client without looking at your role in the interaction. • Try to stay in the here-and-now and focus on the present and ahistorical as much as possible in your response. • Obtain consensual validation by finding out how other members feel. Do so in a way that does not seek to marshal others’ opinion against the feedback, but is in the interest of being complete and comprehensive in your understanding. • Check your internal experience: Does the feedback fit? Is it primarily a transference reaction, or is it in fact a piece of reality about you? If it is reality, you must confirm it; otherwise, you impair rather than facilitate your clients’ reality testing. If it feels like it is off target, then it becomes an opportunity for further work on the client’s patterns in relationships. With these principles as guidelines, the therapist may offer a response such as, “You’re right. There are times when I feel some irritation with you. But at no time do I feel I want to impede your growth, seduce you, get a voyeuristic pleasure from listening to your account of your abuse, or slow your therapy so as to earn more money from you. That simply isn’t part of my experience of you.” Or, “It’s true that I dodge some of your questions. But often I find them unanswerable. You tend to imbue me with too much wisdom. I feel uncomfortable with your deference to me. I often feel that you’ve put yourself down very low, and that you’re looking up at me.” Or, “I’ve rarely heard you challenge me so directly before. Even though it’s a bit scary for me, it’s also very refreshing.” Or, “I feel restrained, very unfree with you, because you give me so much power over you. I feel I have to check every word I say because you give so much weight to all of my statements.” What is common to these therapist responses is that they de-emphasize jargon; they do not overstate the concerns; they avoid adjectives and adverbs that are condemnatory (never say “never”; always avoid “always”). The responses acknowledge the strength and potential of the client and express a wish for the relationship to grow. A mix of therapist confidence and humility is particularly helpful in finding an effective path. Language is a key therapeutic tool of the therapist and we should polish our skills in this domain.57 Harry Stack Sullivan wrote, many years ago, “Words are the implements with which therapists work, attention to their most effective use should be included in teaching psychotherapy.”58 Note that these therapist disclosures are all part of the here-and-now of the group. We advocate that therapists relate authentically to clients in the here-and-now of the therapy hour, not that they reveal their past and present in a detailed manner—although we have never seen harm in therapists answering such broad personal questions as whether they are married or have children, where they are going on vacation, where they were brought up, and so on. Keep in mind that the therapist’s human presence encourages more of the same in the group.59 > A group therapy trainee, Samantha, raised the question, in supervision, of whether or not to share news of her impending wedding and week-long honeymoon with the group. She and I (ML) discussed the fact that it was likely impossible to conceal this information: the group would notice her wedding band when she returned to the next meeting.

So why the hesitancy? What would be the impact of not disclosing this news? In supervision we discussed several salient points. This was a positive development in her life. We expected our clients to share everything with us, and our reluctance to share this kind of news with them would separate us from them. Instead, we could honor their openness with us by reciprocating with information that was in essence public information. Sharing the news of the wedding did not mean talking about the attributes of her partner, or how she had worried she would never find a match. But it did mean respecting the group and trusting them to respond in ways that would be welcoming, or benign, or at most grist for discussion.

We talked as well about the importance of reducing our clients’ shame by our humanness. If we purport ourselves to never being touched by life for better or for worse, it reduces our clients’ willingness to share their disappointments, discouragement, or feelings of shame. Therapist humanness begets therapy humanness. The group responded at the next session with congratulations, wishing Samantha well, thanking her for sharing her good news, and then getting on with their work—a constructive contrast to sitting together and colluding in avoiding an evident fact in the room. << Some therapists carry it much further and may wish to describe some personal problems they encountered and overcame similar to those of group members. We personally have rarely found this useful or necessary.i A study of the effects of therapist disclosure on a group over a seven-month period noted many beneficial effects from therapist transparency.60 First, therapist disclosure was more likely to occur when therapeutic communication among members was not taking place. Second, the effect of therapist disclosure was to shift the pattern of group interaction into a more constructive direction. Finally, therapist self-disclosure resulted in an immediate increase in cohesiveness. Group therapist self-disclosure can serve to promote clients’ relinquishing of old, unhealthy, internalized models of relationships and an openness to new relationships.61 Yet many therapists shrink from self-disclosure without being clear about their reasons for doing so. Perhaps it stems from feeling loyal to an anachronistic model that demands less personal exposure, or from the fear of disrupting therapy boundaries and turning the therapy into a session about the therapist. There is little doubt, we would add, that the personal qualities of a therapist influence professional style, choice of ideological school, preferred clinical models, and use of self.62 In debriefing sessions after termination, we have often discussed therapist disclosure with clients. The great majority have expressed the wish that the therapist had been more open, more personally engaged in the group. Very few would have wanted therapists to have discussed more of their private life or personal problems with them, however. A study of individual therapy had the same findings—clients prefer, and in fact thrive on, therapist engagement, and prefer therapists who are “not too quiet.”63 No one expressed a preference for full therapist disclosure. > Client feedback about therapist transparency is even more impactful when it is provided before therapy ends. Nearing the end of his tenure as a co-leader trainee in an ongoing group, Niran, a Southeast Asian man, teared up, uncharacteristically, as he spoke about leaving the group: “I feel privileged to have worked with this group; I learned a great deal that will help my future clients, and I developed as a group leader—I hope. I also hope I have contributed to the group. I will miss you all.”

One of the group members, Binh, a reserved, anxious, and depressed man, also Southeast Asian, and normally very distant from his emotions, responded that Niran’s openness in the meeting was a gift to him: “I think you and I are alike. It is not easy to show what we feel; that is not how we were raised. Even though you are younger than I am, your manner here reminded me of my father’s silent inscrutability. He was always so silent and distant from his emotions, but every once in a while, he exploded in rage. That is why your showing me warmth and decency means so much to me.”

Niran welcomed the feedback and spoke about how touched he was by Binh ’s comments, saying he would carry that message with him in his future work. << Furthermore, there is evidence that leaders are more transparent than they know. The issue is not that we reveal ourselves—that is unavoidable 64—rather, it is what use we make of our transparency and our clinical honesty. Some self-revelation is inadvertent or unavoidable—for example, pregnancy and bereavement.65 In some groups, particularly homogeneous groups with a focus such as substance abuse, sexual orientation, or specific medical illness, leaders will likely be asked about their personal experience with the common group focus: Have they had personal experience with substance abuse? An eating disorder? Are they part of the LGBTQ community? Have they personally had the medical disease that is the focus of the group? Increasingly, clients will inquire about therapist values and religious beliefs or affiliations, and the growing number of clients from an increasingly wider variety of cultural backgrounds invites questions about the therapist’s cultural identity and personal connection to that culture. The arenas of inquiry are broad and expanding as our field grows beyond its old monochromatic worldview.66 For that reason, it can be helpful to anticipate the inquiry and have clear ethical and therapeutic principles to guide your responses. Although the research literature shows that therapist self-disclosure generally strengthens the therapeutic relationship, such disclosure does require tact, sensitivity, and nuance. We suggest you ask yourself these types of questions: Why am I sharing this information? What is my impact? Could I be foisting my beliefs or identity concerns upon my clients?67 Therapists need to reveal relevant material about themselves in a way that helps group members realize that the therapist can understand and empathize with their experiences. That does not mean, however, that the therapist must provide extensive personal historical details. Such revelations are usually unhelpful to the therapy because they blur the difference in role and function between the therapist and the group members. And always explore with your clients the meaning to them of your self-disclosure. Though members rarely press a therapist for inappropriate disclosure, occasionally one particular personal question arises that group therapists dread. It is illustrated in a dream of a group member shared with me (IY): “The whole group is sitting around a long table with you [the therapist] at the head. You had in your hand a slip of paper with something written on it. I tried to snatch it away from you, but you were too far away.” Months later, after this woman had made some significant personal changes, she recalled the dream and added that she knew all along what I had written on the paper but hadn’t wanted to say it in front of the group. It was my answer to the question, “Do you love me?” This is a threatening question for the group therapist. And there is an even more alarming follow-up question: “How much do you love each of us?” or, “Whom do you love best?” These questions threaten the very essence of the psychotherapeutic contract. They challenge tenets that both parties have agreed to keep invisible. They are but a step away from a commentary on the “purchase of friendship” model: “If you really care for us, would you see us if we had no money?” They come perilously close to the ultimate, terrible secret of the psychotherapist, which is that the intense drama in the group room plays a smaller, more compartmentalized role in his or her life than it does in the lives of the members themselves. The issue of therapist transparency is vastly complicated by widely publicized instances of therapist-client sexual abuse. Unfortunately, the irresponsible or impulse-ridden therapists who, to satisfy their own needs, betray their professional and moral covenant have not only damaged their own clients but caused a backlash that has damaged trust in the client-therapist relationship everywhere, undermining the credibility of our field. It is a commentary on our times that our news cycles are replete with reports of those in power sexually exploiting those who are subordinate to or dependent upon them. Many professional mental health associations have taken a highly reactionary stance toward the professional relationship, advising therapists to practice defensively and always keep potential litigation in mind. The lawyers and juries, they say, will reason that “where there is smoke, there is fire,” and that since every sexual encounter between therapist and client started on the slippery slope of slight boundary crossings, human interactions between client and therapist are in themselves evidence of wrongdoing. Consequently, professional organizations have warned therapists to veer away from the very humanness that is the core of the therapeutic relationship. A leading and still influential article with a high Victorian tone in the American Journal of Psychiatry, for example, advocated a stifling formality and warned psychiatrists not to offer their clients coffee or tea, not to address them by their first names, not to use their own first names, never to run over the scheduled time period, never to see any client during the last working hour of the day (since that is when transgressions most often occur), and never to touch a client—even an act such as squeezing the arm or patting the back of an AIDS patient who needs therapeutic touch should be scrutinized and documented.ii Obviously, these instructions and the sentiment behind them are deeply corrosive to the therapeutic relationship. To their credit, the authors of the original article recognized the antitherapeutic impact of their first article and wrote a second paper five years later aimed at correcting the overreaction it had generated. The second article pled for common sense and for recognition of the importance of the clinical context in understanding or judging boundary issues in therapy. The later article aptly distinguished between boundary crossings—therapeutic actions that humanize the therapy and are in the service of the client—and boundary violations—therapeutic transgressions driven by the therapist that damage the client and the therapy. Therapists are always encouraged to be reflective and to obtain consultation or supervision whenever they are uncertain about their therapeutic posture or actions.68 Certainly, there is a proper place for therapist concealment, and the most helpful therapist is by no means the one who is most fully and most consistently self-disclosing. Let us turn our attention to the perils of transparency. Pitfalls of Therapist Transparency Some time ago I (IY) observed a group led by two neophyte therapists who were at that time much dedicated to the ideal of therapist transparency. They formed an outpatient group and conducted themselves in an unflinchingly honest fashion, expressing openly in the first meetings their uncertainty about group therapy, their inexperience, their self-doubts, and their personal anxiety. One might admire their courage, but not their results. In their overzealous obeisance to transparency, they neglected their function of group maintenance, and the majority of the members dropped out of the group within the first six sessions. The leader who strives only to create an atmosphere of egalitarianism between member and leader may in the long run provide no leadership at all. Effective leader role behavior is by no means unchanging; as the group develops and matures, different forms of leadership are required.69 “The honest therapist,” as Morris B. Parloff noted, “is one who attempts to provide that which the client can assimilate, verify and utilize.”70 Sándor Ferenczi, years ago, underscored the necessity for proper timing. The analyst, he said, must not admit his flaws and uncertainty too early.71 Research on group members’ attitudes toward therapist self-disclosure points to the importance of timing and the content of disclosure.72 Therapists’ disclosures that are judged as harmful in early phases of the group may be considered facilitative as a group matures. Furthermore, experienced group members are far more desirous of therapist self-disclosure than are inexperienced group members. Content analysis demonstrates that members prefer leaders who disclose positive ambitions (for example, personal and professional goals) and personal emotions (loneliness, sadness, anger, worries, and anxieties); they disapprove of a group leader expressing negative feelings about any individual member or about the group experience (for example, boredom or frustration).73 Not all emotions can be expressed by the therapist. Expressing hostility is almost invariably damaging and often irreparable, contributing to premature termination and negative therapy outcomes.74 Our language skills are seminal strengths—finding palatable ways of saying unpalatable things allows us to maintain our authenticity and our empathy while fulfilling our therapeutic mandate and responsibility of “first do no harm.”75 Is full disclosure even possible in the therapy group or in the outside world? Or desirable? Some degree of personal and interpersonal concealment is an integral ingredient of any functioning social order. Eugene O’Neill illustrated this in dramatic form in the play The Iceman Cometh.76 A group of derelicts live, as they have for twenty years, in the back room of a bar. The group is exceedingly stable, with many well-entrenched group norms. Each man maintains himself by a set of illusions (“pipe dreams,” O’Neill calls them). One of the most deeply entrenched group norms is that no member may challenge another’s pipe dreams. Then enters Hickey, the iceman, a traveling salesman, a false prophet who believes he brings fulfillment and lasting peace to each man by forcing him to shed his self-deceptions and stare with unblinking honesty at his life. Hickey’s surgery is deft. He forces Jimmy Tomorrow (whose pipe dream is to get his suit out of hock, sober up, and get a job “tomorrow”) to act now. He gives him clothes and sends him, and then the other men, out of the bar to face today. The effects on each man and on the group are calamitous. One commits suicide, others grow severely depressed, “the life goes out of the booze,” the men attack one another’s illusions, the group bonds disintegrate, and the group veers toward dissolution. In a sudden, last-minute, convulsive act, the group labels Hickey psychotic, banishes him, and gradually reestablishes its old norms and cohesion. These “pipe dreams”—or “vital lies,” as Henrik Ibsen called them in The Wild Duck 77—are often essential to personal and social integrity. They should not be taken lightly or impulsively stripped away in the service of honesty. Commenting on the social problems of the United States, Viktor Frankl once suggested that the Statue of Liberty on the East Coast be counterbalanced by a Statue of Responsibility on the West Coast.78 In the therapy group, freedom becomes possible and constructive only when it is coupled with responsibility. None of us is free from impulses or feelings that, if expressed, could be destructive to others. We suggest that we encourage clients and therapists to speak freely, to shed all internal censors and filters save one—the filter of responsibility to others. We do not mean that unpleasant sentiments are never to be expressed; indeed, growth cannot occur in the absence of conflict. We do mean, however, that responsibility, not total disclosure, is the superordinate principle. The therapist has a particular type of responsibility—responsibility to clients and to the task of therapy. Group members have a human responsibility toward one another. As therapy progresses, as solipsism diminishes, as empathy increases, they come to exercise that responsibility in their interactions among themselves. Thus, your raison d’être as group therapist is not primarily to be honest or fully disclosing. You must be clear about why you reveal yourself. What impact can you anticipate from your self-disclosure? In times of confusion about your behavior, you may profit from stepping back momentarily to reconsider your primary tasks in the group. Therapist self-disclosure is an aid to the group because it sets a model for the clients and permits some members to reality-test their feelings toward you. When considering a self-disclosure, ask yourself where the group is now. Is it a concealed, overly cautious group that may profit from a leader who models personal self-disclosure? Or has it already established vigorous self-disclosure norms and is in need of other kinds of assistance? Again, you must consider whether your behavior will interfere with your group-maintenance function. You must know when to recede into the background. Unlike the individual therapist, the group therapist does not have to be the axle of therapy. In part, you are midwife to the group: you must set a therapeutic process in motion and take care not to interfere with that process by insisting on your centrality. An overly restricted definition of the role of group therapist—whether based on transparency or any other criterion—may cause the leader to lose sight of the individuality of each client’s needs. Despite your group orientation, you must retain some individual focus; not all clients need the same thing. Some, perhaps most, clients need to relax controls; they need to learn how to express their affect, whatever it may be—anger, love, tenderness, hatred. Others, however, need the opposite: they need to gain impulse control because their lifestyles are already characterized by labile, immediately acted-upon affect. One final consequence of more or less unlimited therapist transparency is that the cognitive aspects of therapy may be completely neglected. As we noted earlier, mere catharsis is not in itself a corrective experience. Cognitive learning or restructuring (much of which is provided by the therapist) seems necessary for the client to be able to generalize group experiences to outside life. Without the acquisition of some knowledge about general patterns in interpersonal relationships, the client may, in effect, have to reinvent the wheel in each subsequent interpersonal transaction. Footnotes i A small study of individual therapy demonstrated that certain non-here-and-now therapist self-disclosure could be effective in strengthening the real (nontransference) relationship between client and therapist. Personal disclosure by the therapist about common interests or activities, when it followed the client’s lead, served to normalize and support clients and indirectly deepened their learning. See S. Knox, S. Hess, D. Peterson, and C. Hill, “A Qualitative Analysis of Client Perceptions of the Effects of Helpful Therapist Self-Disclosure in Long-Term Therapy,” Journal of Counseling Psychology 49 (1997): 274–83. ii We recall, not that long ago, booths at psychotherapy conferences at which manufacturers promoted video systems that therapists could use to record every session as a safeguard against frivolous litigation. Chapters 8 Selecting Clients and Composing Groups GOOD GROUP THERAPY BEGINS WITH GOOD CLIENT SELECTION. Clients improperly assigned to a therapy group are unlikely to benefit from their therapy experience. Furthermore, a poorly composed group may not be helpful to its members or may even disintegrate early in its life. It is therefore understandable that contemporary psychotherapy researchers are actively examining how best to match clients to psychotherapy groups according to their specific characteristics.1 In this chapter we begin by considering both the research evidence bearing on selection and the clinical methods of determining whether a given individual is a suitable candidate for group therapy. We next address the question of group composition: once it has been decided that a client is a suitable group therapy candidate, into which specific group should he or she go? Group therapy is complex, and at every step of the way the group leader should be guided by this question: What must I do to ensure the success of this group? We focus particularly on a specific type of group therapy: the heterogeneous outpatient group pursuing the ambitious goals of symptomatic relief and characterological change. However, many of the general principles we discuss have relevance to other types of groups as well, including the brief problem-oriented group.2 Here, as elsewhere in this book, we provide the reader with fundamental group therapy principles coupled with strategies for adapting these principles to a wide variety of clinical situations. (We will discuss some more specialized clinical situations in Chapter 15.) We would only refer a client to group therapy if we believe that this would be an effective form of treatment for that individual. We start therefore with observations about the benefits of group therapy. Research consistently shows that group therapy is a potent modality producing significant benefit to its participants.3 It also indicates that group therapy offers unique benefits that in certain situations may make it more helpful than individual therapy. The evidence for the effectiveness of group therapy is so persuasive that some experts advocate that group therapy be utilized as the primary model of contemporary psychotherapy, though they also acknowledge that it is a more complex treatment that requires therapists have specific training.4 Individual therapy may be preferable for clients who require active clinical management, or when relationship issues are less important and personal insight and depth understanding are particularly important.5 Group therapy is superior to individual therapy in providing social learning and in helping clients develop social support and improve social networks, factors of great importance for clients with substance use disorders.6 Clients with a medical illness acquire coping skills better in therapy with a group of peers than in individual therapy.7 Adding group therapy to the treatment of women who are survivors of childhood sexual abuse provides benefits beyond individual therapy: it results in reduced shame and greater empowerment and psychological well-being.8 Of course, personal choice matters. Clients tend to do better when they engage the type of therapy they prefer: a therapy that matches their expectations.9 We also recognize that clients may be reluctant to engage in group therapy for a host of reasons that the group leader will need to address as part of the selection and preparation process—an issue we will discuss later in this chapter.10 Predicting which clients will do best in group therapy and which are better referred to another form of therapy is not a simple matter. Each client is different, and decisions about treatment must be tailored to the individual. Our inclusion and exclusion criteria are best viewed as general guidelines, and even experienced clinicians are often surprised by who does much better or much worse than expected.11 Our limited clinical capacity to evaluate who will do well, and how our clients are actually doing, is part of the rationale for incorporating more empirical measurement in our clinical care.12 In many instances, the variables that seem to forecast a client’s failure in group therapy can be offset by thorough preparation, through empathic therapist responsiveness, and by securing a fit with a group that is better suited to that particular client at that point in the client’s treatment trajectory. We want to get this process as right as possible to safeguard the client’s care and to avoid the impact on the entire group of a member who is a poor fit. CRITERIA FOR EXCLUSION Question: How do group clinicians select clients for group psychotherapy? Answer: The great majority of clinicians do not select for group therapy. Instead, they deselect. Given a pool of clients, experienced group therapists determine that certain people cannot possibly work in a therapy group and should be excluded. And then they proceed to accept all the other clients. That approach seems crude. We would all prefer the selection process to be more elegant, more finely tuned. But, in practice, it is far easier to specify exclusion than inclusion criteria; one characteristic may be sufficient to exclude an individual, whereas a more complex profile must be delineated to justify inclusion. Mistakes in selection are costly not only to the individual client but to the entire group. Here is a major guideline: We can predict that clients will fail in group therapy if they are unable to participate in the primary task of the group, be it for logistical, intellectual, psychological, or interpersonal reasons. There is considerable and consistent clinical consensus13 that clients are poor candidates for a heterogeneous outpatient therapy group if they have a significant brain injury,14 are paranoid,15 somatizing,16 addicted to drugs or alcohol,17 acutely psychotic,18 or antisocial.19 More recent studies using validated questionnaires like the Group Selection Questionnaire (GSQ) or the Group Therapy Questionnaire (GTQ) echo this clinical consensus and expand it by indicating that a certain degree of interpersonal skill is required to work in an interpersonal group.20 An additional important point: if clients have no expectation of the group being of value, there is little chance of a successful outcome, and the therapeutic alliance—the alignment of client and therapist about the goals and tasks and quality of the therapeutic relationship—is undermined from the start.21 These considerations are even more compelling for brief, time-limited groups, which are particularly unforgiving of poor client selection. What traits must a client possess to participate in a dynamic, interactional therapy group? Members must have a capacity and willingness to examine their interpersonal behaviors, to self-disclose, to reflect psychologically on themselves and others, to give and receive feedback, and to have some capacity and willingness to engage with the other group members. Unsuitable clients are those who tend to construct an interpersonal role that is rigid and that would prove detrimental to themselves as well as to the group. For such clients the group becomes a venue for re-creating and reconfirming maladaptive patterns. Antisocial clients are exceptionally poor candidates for interactional group therapy. Although early in therapy they may be influential and active members, they will eventually manifest their basic inability to relate, often with considerable dramatic and destructive impact, as the following clinical example illustrates: > Felix, a highly intelligent thirty-five-year-old man with a history of alcoholism and impoverished, exploitative interpersonal relationships, was added with two other new clients to an ongoing group that had been reduced to three by the recent graduation of members. The group had shrunk so much that it seemed in danger of collapsing, and the therapists were eager to reestablish its size. They realized that Felix was not an ideal candidate, but they had few referrals and decided to take the risk. In addition, they were intrigued by his stated determination to change his lifestyle. (Many antisocial individuals are forever “reaching a turning point in life.”)

By the third meeting, Felix had become the social and emotional leader of the group. He seemed to feel more acutely and suffer more deeply than the other members. He presented the group, as he had the therapists, with a largely fabricated account of his background and current life situation. By the fourth meeting, as the therapists learned later, he had seduced one of the female members, and in the fifth meeting he spearheaded a discussion of the group’s dissatisfaction with the brevity of the meetings. He proposed that the group, with or without the permission of the therapists, meet more often, perhaps at one of the members’ homes, without the therapists. By the sixth meeting, Felix had vanished, without notifying the group. The therapists learned later that he had suddenly decided to take a two-thousand-mile bicycle trip, hoping to sell an article about it to a magazine. << This extreme example illustrates many of the reasons why the inclusion of antisocial and exploitative individuals in heterogeneous outpatient groups is ill advised. Their social fronts are deceptive; they often consume such an inordinate amount of group energy that their departure leaves the group bereft, puzzled, and discouraged; they rarely assimilate the group therapeutic norms and instead often exploit other members and the group as a whole for their immediate gratification. We do not mean that group therapy per se is always contraindicated for antisocial clients. In fact, a specialized form of group therapy with a more homogeneous population and a wise use of strong group and institutional pressure may well be the treatment of choice.22 Most clinicians agree that clients in the midst of some acute situational crisis are not good candidates for group therapy; they are far better treated in a crisis-intervention therapy format.23 Deeply depressed suicidal clients are best not placed in an interactionally focused heterogeneous therapy group because the group cannot give them the specialized attention they require (except at enormous expense of time and energy to the other members); furthermore, the threat of suicide or self-harm is too taxing, too anxiety provoking, for the other group members to manage.24 This does not rule out group therapy for these clients, but they may require group therapy combined with individual therapy. Structured homogeneous groups for clients with chronic suicidality may be quite effective.25 Good attendance is so necessary for the development of a cohesive and effective group that it is wise to exclude clients who, for any reason, may not attend regularly. Poor attendance may be due to unpredictable and hard-to-control work demands, and it is best not to place individuals in the group whose work requires extensive travel that would cause them to miss even one out of every four or five meetings. Similarly, we are hesitant to select clients who have a very long commute to the group. Too often, especially early in the course of a group, a client may feel neglected or dissatisfied with a meeting, perhaps because another member may have received the bulk of the group time and attention, or the group may have been busy building its own infrastructure—work that may not offer obvious immediate gratification. Deep feelings of frustration may, if coupled with a long, strenuous commute, dampen motivation and result in sporadic attendance. Obviously, there are many exceptions: some therapists tell of clients who faithfully fly to meetings from remote regions month after month or make a long commute through the winter season. One group member reliably left work in another city at 3:30 p.m. to attend a 6:00 p.m. group, getting home close to 10:00 p.m. each week. She was determined “to make the drive to the group worthwhile,” and her manifest commitment to the group was cited by others as reinforcing their valuing of the group. As a general rule, however, the therapist does well to take account of hardships imposed by time and distance. Online groups are an exception to this concern. Exclusion criteria apply only for the type of group under consideration. Almost all clients will fit into some group. A characteristic that excludes someone from one group may be the exact feature that secures entry into another group. In our breast cancer group work, for example, women with advanced, metastatic disease fit poorly in groups in which most of the other women had early breast cancer—a cancer that carried a much better and much less frightening prognosis. A secretive, non-psychologically minded client with an eating disorder is generally a poor candidate for a long-term interactional group, but may be ideal for a homogeneous, cognitive-behavioral eating-disorders group. And keep in mind that some individuals may fail in their first interpersonal group, learn from that experience, and thrive in a later group. Dropouts There is evidence that premature termination from group therapy is bad for the client and bad for the group. A pioneering study of thirty-five clients who dropped out of long-term heterogeneous interactional outpatient groups in twelve or fewer meetings found that only three reported themselves as improved.26 Moreover, those three individuals had only marginal symptomatic improvement. None of the thirty-five clients left therapy because they had satisfactorily concluded their work; they had all been dissatisfied with the therapy group experience. Their premature terminations also had an adverse effect on the remaining members of their group, who were threatened and demoralized by the early dropouts. In fact, many group leaders report a contagion or “wave effect,” with dropouts begetting other dropouts. The proper development of a group requires membership stability; a rash of dropouts may delay or obstruct the maturation of a group for months. Early group termination is thus a failure for the individual and a detriment to the therapy of the remainder of the group. Unfortunately, dropping out prematurely is common across the psychotherapies.27 Reviews of dropout rates in group therapy across a range of settings, from private practice to university hospital clinics to VA outpatient clinics, consistently demonstrate group therapy attrition ranges from 17 percent to 57 percent.28 Although this rate is no higher than the dropout rate from individual therapy, the dropout phenomenon is more concerning to group therapists because of the deleterious effects of dropouts on the rest of the group. A study of early dropouts may help establish sound exclusion criteria and, furthermore, may provide an important goal for the selection process. If, in the selection process, we learn merely to screen out members particularly vulnerable to dropping out of therapy, that in itself would constitute a major achievement. It would allow us to direct these clients to other treatments, to invest much more in their pregroup preparation, or to be alert to our own countertransference contributions to their negative group experience. Although the early terminators are not the only failures in group therapy, they are unequivocal failures.29 We may dismiss as unlikely the possibility that early dropouts have gained something positive that will manifest itself later. As noted in an earlier outcome study of encounter group participants, those who reported a negative experience when they left the group continued to feel that way long after the group ended. When interviewed six months later, none of these participants reported having “put it all together” and enjoying a delayed benefit from the group experience.30 If they left the group shaken or discouraged, they were very likely to remain that way. Keep in mind that the study of group dropouts tells us little about those who continued to attend. Group continuation is a necessary but insufficient factor in successful therapy, although consistent evidence exists that clients who continue in treatment and avoid a premature ending achieve the best therapy outcomes.31 Reasons for Dropouts and Premature Termination A number of rigorous studies of group therapy in various settings have convergent findings on the characteristics of people who drop out prematurely from group therapy.32 These studies demonstrate that such clients are likely, at the initial screening or in the first few meetings, to have one or more of the following characteristics: • Lower psychological-mindedness • Tendency to act out • Lower motivation • More reactive and less reflective • Less positive emotion • Greater denial of distress or need for therapy • Higher somatization • Abuse of substances • Greater anger and hostility • Lower socioeconomic status • Lower social effectiveness • Lower intelligence • Lack of understanding of how group therapy works • The experience or expectation of cultural insensitivity • Poorer social skills • Very high levels of emotional or psychological distress • In acute crisis and unable to turn attention to the group • Strong preference for individual therapy • Early dissatisfaction with the group or group leader TABLE 8.1 Group Therapy Dropout Rates Type of Group: University outpatient clinic Length of Group: General, open-ended Number of Sessions: 12 or fewer Percent Dropping Out: 50%1 Type of Group: University outpatient clinic Length of Group: Bereavement, closed Number of Sessions: 12 or fewer Percent Dropping Out: 28%2 Type of Group: University outpatient clinic Length of Group: Short-term Number of Sessions: 8 or fewer Percent Dropping Out: 39%3 Type of Group: University outpatient clinic Length of Group: Open-ended Number of Sessions: 3 or fewer Percent Dropping Out: 57%4 Type of Group: VA outpatient clinic Length of Group: Open-ended Number of Sessions: 9 or fewer Percent Dropping Out: 51%5 Type of Group: VA outpatient clinic Length of Group: Open-ended Number of Sessions: 16 or fewer Percent Dropping Out: 50%6 Type of Group: University outpatient clinic Length of Group: Open-ended Number of Sessions: 12 or fewer Percent Dropping Out: 35%7 Type of Group: Private and clinic Length of Group: Open-ended Number of Sessions: 3 or fewer Percent Dropping Out: 30%8 Type of Group: Clinic and hospital Length of Group: Inpatient and outpatient Number of Sessions: 20 or fewer Percent Dropping Out: 25%9 Type of Group: Private practice Length of Group: Long-term, analytic Number of Sessions: 12 months or less Percent Dropping Out: 35%10 Type of Group: Outpatient clinic Length of Group: Open-ended Number of Sessions: 12 or fewer Percent Dropping Out: 17%11 Type of Group: Outpatient clinic Length of Group: Short-term Number of Sessions: 5 or fewer Percent Dropping Out: 17%12 Type of Group: Private and clinic Length of Group: Analytic Number of Sessions: 10 or fewer Percent Dropping Out: 24%13 Type of Group: Clinic Length of Group: Dynamically oriented Number of Sessions: 6 months or less Percent Dropping Out: 17%14 Type of Group: Private practice Length of Group: Dynamic/analytic Number of Sessions: 6 months or less Percent Dropping Out: 27% therapist A 38% therapist B15 Type of Group: Private practice Length of Group: Analytic/long-term Number of Sessions: 1 year or less Percent Dropping Out: 55%16 Type of Group: University counseling center Length of Group: Interactional/ interpersonal Number of Sessions: 12 or fewer Percent Dropping Out: 31% therapist A 45% therapist B17 Type of Group: Outpatient clinic Length of Group: Complicated grief Number of Sessions: 8 or fewer Percent Dropping Out: 23%18 Type of Group: Outpatient clinic Length of Group: CBT for depression Number of Sessions: 12 or fewer Percent Dropping gOut: 48%19 Sources: 1. R. Klein and R. Carroll, “Patient Characteristics and Attendance Patterns in Outpatient Group Psychotherapy,” International Journal of Group Psychotherapy 36 (1986): 115–32. 2. M. McCallum and W. Piper, “A Controlled Study for Effectiveness and Patient Suitability for Short-Term Group Psychotherapy,” International Journal of Group Psychotherapy 40 (1990): 431–52. 3. M. McCallum, W. Piper, and A. Joyce, “Dropping Out from Short-Term Group Therapy,” Psychotherapy 29 (1992): 206–13. 4. E. Nash et al., “Some Factors Related to Patients Remaining in Group Psychotherapy,” International Journal of Group Psychotherapy 7 (1957): 264–75. 5. B. Kotkov, “The Effects of Individual Psychotherapy on Group Attendance,” International Journal of Group Psychotherapy 5 (1955): 280–85. 6. S. Rosenzweig and R. Folman, “Patient and Therapist Variables Affecting Premature Termination in Group Psychotherapy,” Psychotherapy: Theory, Research and Practice 11 (1974): 76–79. 7. I. Yalom, “A Study of Group Therapy Dropouts,” Archives of General Psychiatry 14 (1966): 393–414. 8. E. Berne, “Group Attendance: Clinical and Theoretical Considerations,” International Journal of Group Psychotherapy 5 (1955): 392–403. 9. J. Johnson, Group Psychotherapy : A Practical Approach (New York: McGraw-Hill, 1963). 10. M. Grotjahn, “Learning from Dropout Patients: A Clinical View of Patients Who Discontinued Group Psychotherapy,” International Journal of Group Psychotherapy 22 (1972): 306–19. 11. L. Koran and R. Costell, “Early Termination from Group Psychotherapy,” International Journal of Group Psychotherapy 24 (1973): 346–59. 12. S. Budman, A. Demby, and M. Randall, “Short-Term Group Psychotherapy: Who Succeeds, Who Fails,” Group 4 (1980): 3–16. 13. M. Weiner, “Outcome of Psychoanalytically Oriented Group Therapy,” Group 8 (1984): 3–12. 14. W. Piper, E. Debbane, J. Blenvenu, and J. Garant, “A Comparative Study of Four Forms of Psychotherapy,” Journal of Consulting and Clinical Psychology 52 (1984): 268–79. 15. W. Stone and S. Rutan, “Duration of Treatment in Group Psychotherapy,” International Journal of Group Psychotherapy 34 (1984): 93–109. 16. K. Christiansen, K. Valbak, and A. Weeke, “Premature Termination in Analytic Group Therapy,” Nordisk-Psykiatrisk-Tidsskrift 45 (1991): 377–82. 17. R. MacNair and J. Corazzini, “Clinical Factors Influencing Group Therapy Dropouts,” Psychotherapy: Theory, Research, Practice and Training 31 (1994): 352–61. 18. M. McCallum, W. Piper, J. Ogrodniczuk, and A. Joyce, “Early Process and Dropping Out from Short-Term Group Therapy for Complicated Grief,” Group Dynamics: Theory, Research, and Practice 6 (2002): 243–54. 19. T. Oei and T. Kazmierczak, “Factors Associated with Dropout in a Group Cognitive Behavior Therapy for Mood Disorders,” Behaviour Research and Therapy 35 (1997): 1025–30. These conclusions suggest that, all too often, the rich get richer and the poor get poorer. What a sad paradox! The clients who have the least skills and attributes needed for working in a group, who most need what the group has to offer, are the very ones most likely to fail! It is this irony that has stimulated attempts to modify the therapy group experience so that it accommodates more of these at-risk clients. We need to fit our groups to our clients rather than the other way around.33 Keep in mind that these characteristics should therefore be seen as relative cautions rather than absolute contraindications. The person who fails in one group may do well in a different one. We should aim to reduce, not eliminate, dropouts. If we create groups that never experience a dropout, then it may be that we are setting our bar for entry too high, thus eliminating clients whom we may be able to help. We will discuss one final study here in great detail, since it has considerable relevance for the selection process and its findings have been replicated in other studies.34 I (IY) studied the first six months of nine therapy groups in a university teaching hospital outpatient clinic and investigated all clients who terminated in twelve or fewer meetings. A total of ninety-seven clients were involved in these groups (seventy-one original members and twenty-six later additions); of these, thirty-five were early dropouts. Considerable data were generated from interviews and questionnaire studies of the dropouts and their therapists and from observers of the groups. An analysis of the data revealed nine major reasons for the clients dropping out of therapy: 1. External factors 2. Group deviancy 3. Problems of intimacy 4. Fear of emotional contagion 5. Inability to share the therapist 6. Complications of concurrent individual and group therapy 7. Early provocateurs 8. Inadequate orientation to therapy 9. Complications arising from subgrouping Usually more than one factor is involved in the decision to terminate. Some factors are more closely related to external circumstances or to enduring character traits that the client brings to the group, and thus are relevant to the selection process, whereas others are related to therapist actions, or to problems arising within the group (for example, the therapist’s skill and competence).35 Most relevant to the establishment of useful selection criteria are the clients who dropped out because of external factors, group deviancy, and problems of intimacy. External Factors. Logistical reasons for terminating therapy (for example, irreconcilable scheduling conflicts, or moving out of the geographic area) played a negligible role in decisions to terminate. When this reason was offered by the client, closer examination usually revealed that group-related stress was more pertinent to the client’s departure. Nevertheless, in the initial screening session, the therapist should always inquire about any pending major life changes, such as a move and the client’s capacity to commit to the group at the planned time. Although clients show variable rates of progress in treatment, there is considerable evidence that therapy aimed at both relieving a client’s symptoms and making major changes in his or her underlying character structure is not brief therapy—a minimum of six months is necessary.36 Hence, clients should not be accepted into such therapy if there is a considerable likelihood of forced termination within the next few months. Instead, these clients are better candidates for shorter-term, problem-oriented groups. External stress was considered a factor in the premature dropout of several clients who were so disturbed by external events in their lives that it was difficult for them to expend the energy for involvement in the group. They could not explore their relationships with other group members while they were consumed with the threat of disruption of relationships with the most significant people in their lives. It seemed especially pointless and frustrating to them to hear other group members discuss their problems when their own problems seemed so compelling. Among the external stresses were severe marital discord with impending divorce, impending career or academic failure, disruptive relationships with family members, bereavement, and severe physical illness. In such instances, referrals should be made to groups explicitly designed to deal with such situations: acute grief, for example, is generally a time-limited condition, and the acutely bereaved client is best referred to a shorter-term bereavement group, particularly if the grief is complex and unremitting.37 Note an important difference! If the goal is specifically to ameliorate the pain of a breakup, then a brief, problem-oriented therapy is indicated. But for clients who wish to change something in themselves that causes them to thrust themselves repeatedly into painful situations (for example, repetitive involvement with people who invariably leave them), then longer-term group work is indicated. The importance of external stress as a factor in premature group termination was difficult to gauge, since often it appeared secondary to internal forces. A client’s psychic turmoil may cause disruption of his or her life situation, so that secondary external stress occurs; or a client may magnify external problems to escape anxiety originating from the group therapy. Several clients considered external stress the chief reason for termination, but in each instance, careful study suggested that external stress was, at best, a contributory, rather than a sufficient, cause for the dropout. In the selection process, therefore, consider a client’s unwarranted focus on external stress to be an unfavorable sign for intensive group therapy. If such a client does enter group therapy, try to encourage the client to keep attending while addressing the external stressor—a new job, for example, that appears to prohibit leaving work in time to attend the group. As the client’s resistance is worked through, often the external stressor becomes more manageable. Group Deviancy. Studying group therapy dropouts who were identified as group deviants offers rich information relevant to the selection process. But first, the term deviant must be carefully defined. We use the word to describe a member who does not fit into a particular group in a substantive way that interferes with the group task. Almost every group member is a group outlier on one key characteristic: the youngest member, the oldest member, the only unmarried member, the only LGBTQ member, the sickest, the only Asian American, the only student, the angriest, the quietest. However, in this study, one-third of the dropouts deviated significantly from the rest of the group in areas crucial to their group participation. The behavior of these clients in the group varied: some were silent, and others were loud, angry group disrupters. But all were isolates and were perceived by the therapists and by the other members as obstructing the progress of the group. The group and the therapists described them as “just not fitting in.” Indeed, often the deviants said that of themselves. They failed to appreciate psychological process, were disengaged or concrete and directive, and were disconnected from the here-and-now of the group. The most commonly described characteristics were a lack of psychological-mindedness and a lack of interpersonal sensitivity. They tended to have a lower socioeconomic status and educational level than the rest of the group members. In terms of communication, they remained at the symptom-describing, advice-giving and -seeking, or judgmental level, avoiding discussion of immediate feelings and here-and-now interaction. Similar results have been reported by others.38 An important subcategory of dropouts had chronic mental illness and were making a marginal adjustment. Given the negative psychological impact of high expressed emotionality on clients with chronic mental illness such as schizophrenia, an intensive interactional group therapy would be contraindicated in their treatment. Structured, supportive, and psychoeducational groups are more effective.39 Notably, two clients in the study who did not drop out differed vastly from the other remaining members in their life experience. One had a history of prostitution, the other had prior problems with drug addiction and drug dealing. However, these clients did not differ from the others in ways that impeded the group’s progress (psychological insight, interpersonal sensitivity, and effective communication) and never became group deviants. The group deviancy findings of this study are consistently echoed by social psychology research, clinical experience, and the use of new selection aids, such as the Group Selection Questionnaire. A summary of this literature highlights what most group leaders have experienced firsthand. Clients who do not fit with the group are unlikely to benefit, even if much initial attention is directed to them. These clients slow the group down. They undermine the group’s interactional process by a rigid, controlling, or dismissive style and adversely impact the other group members. They lack motivation for change. The group deviant re-creates his core difficulties in the social microcosm of the group but lacks the psychological capacity to reflect on these difficulties and work with them, often damaging his self-esteem and others’ therapeutic work. The group holds no real sway or influence on the deviant, and group members will sooner or later disengage from the deviant in futility. These group members typically experience lower group social status, which diminishes personal well-being and has a negative impact on the individual’s emotional experience in social groups.40 A closer look at one of the group deviants in this study is illustrative. This man—middle-aged, isolated, and rigidly defended—was able to continue in the group because of the massive support he received in concurrent individual therapy. However, he remained an isolate in the group and, in the opinion of the therapists and the other members, impeded the group’s progress. At first, considerable group energy was expended on him; eventually the group gave up, and he was, to a great extent, excluded from the communicational network. But the group could never entirely forget or ignore him, which slowed the pace of the work. If there is something important going on in the group that cannot be talked about, there will always be a degree of inhibition in communication. With a disenfranchised member, the group is never really free; in a sense, it cannot move much faster than its slowest member. Morton Lieberman, Matthew Miles, and I (IY) demonstrated that deviant group members (members considered “out of the group” by the other members, or members who grossly misperceived the group norms) had virtually no chance of benefiting from the group and an increased likelihood of suffering negative consequences.41 Now, let’s apply these research findings and clinical observations to the selection process. The clients who will assume a deviant role in therapy groups are not difficult to identify in screening interviews. Their denial, their de-emphasis of intrapsychic and interpersonal factors, their unwillingness to be influenced by interpersonal interaction, and their tendency to attribute distress to somatic and external factors will be evident in a carefully conducted interview. Some of these individuals stand out by virtue of significantly greater impairment in function. They are often referred to group therapy by their individual therapists, who feel discouraged or frustrated by their client’s lack of progress—perhaps hoping to transfer care away from the individual setting. Occasionally, postponing entry into group therapy may be appropriate, with group therapy becoming possible at a later date. The deferral can provide time for clients to benefit from psychopharmacological treatment, or to consolidate some stability through individual therapy. Clinicians often err in assuming that even if certain clients will not click with the rest of the group, they will nevertheless benefit from the overall group support and the opportunity to improve their socializing techniques. In our experience, this expectation is rarely realized. Eventually the group will extrude the deviant. Therapists also tend to withdraw overtly and covertly from such clients, putting their therapeutic energies into those clients who reward their effort.42 Occasionally however, clients whose initial clinical presentation suggests that their selection and group entry will end in therapeutic failure can achieve a surprisingly positive outcome. > Sandra, a divorced sixty-year-old woman, was referred by her psychiatrist to a newly forming interpersonal thirty-two-session group. She had a history of intense social isolation and a significant problem with hoarding. So great was her shame about hoarding that she had avoided any discussion of it even in a homogeneous group focused on hoarding. She skipped meetings and refused to participate when she did attend. Sandra was referred this time to an interpersonal group with the hope of reducing her anxious avoidance and intense social isolation. She would continue in individual treatment as well.

In the first pregroup assessment meeting, what jumped out to me (ML) were all the reasons her group therapy would likely fail again. Sandra evinced many of the factors we have just reviewed: an odd and eccentric presentation with mismatched clothes, intense social avoidance, a sense of shame about the hoarding and unwillingness to talk about it, and interpersonal rigidity. We also discussed her failure in prior group therapy. She was, however, persuasive in the pregroup assessment, articulating that she was determined not to fail this group as she had done with prior groups. Moreover, as the interview progressed, despite the first impression she made, I found Sandra engaging.

We determined together that the focus of her group work would be engaging other members and managing the emotions that would emerge. She agreed that no matter the nature of her distress, she would speak of it in the group. To her credit, she began the first session talking about her wish not to fail or flee. She described her life-long expectation of interpersonal catastrophes and her dread of rejection, humiliation, and shame. The other group members appreciated her openness and courage. There were a few early crises that prompted Sandra to email after meetings asking if she should continue in the group. She was concerned about her misinterpretation of others’ actions, her overreaction to group events, and her great fear that the other members would ask her to leave. In each such instance, however, the group and I offered support. She attended thirty of the thirty-two meetings and graduated as a valued member of the group, feeling “human among other humans.”43 << To summarize, it is important that the therapist screen out clients who are likely to become marked deviants in the group for which they are being considered. Augmenting a clinical assessment with empirical measures, such as the Group Selection Questionnaire, can be very helpful. Selection, however, is still an inexact science; clients become deviants because of their interpersonal behavior in the group sessions, not because of a deviant lifestyle or history. Problems of Intimacy. Several clients dropped out of group therapy because of conflicts associated with intimacy, manifested in various ways, including schizoid withdrawal, uninhibited or overly inhibited self-disclosure, and unrealistic demands for instant intimacy.i Several clients who were diagnosed as having a schizoid personality disorder (reflecting their social withdrawal, interpersonal coldness, aloofness, introversion, and tendency toward internal preoccupation) experienced considerable difficulty relating and communicating in the group. Each began the group resolved to express feelings and to correct previous maladaptive patterns of relating, but each failed to accomplish this aim and experienced frustration and anxiety. Their therapists described these members as “isolates,” “silent members,” “peripheral members,” and “nonrevealers.” In contemporary diagnostic terms, some of the group members diagnosed then as schizoid might well today be diagnosed with Level 1 Autism. The clinical distinction can be quite subtle. Significant impairments in relationshipsare characteristic of individuals in both diagnostic groups. The schizoid individual’s impairment is a lack of interest in others, detachment, emotional flatness, and preference for isolation.44 Individuals with autism spectrum disorder, in contrast, generally miss social cues and are often socially anxious, and eager for social contact—but at a loss as to how to get it right. They may make good use of structured social skills groups that de-emphasize interpersonal exploration.45 Most of the schizoid group members in this study terminated treatment discouraged about the possibility of ever obtaining help from group therapy (see Chapter 12). Another intimacy-conflicted client dropped out for a different reason—his fear of his own aggression against other group members. He originally applied for treatment because of his “fear of killing someone when I explode… which results in my staying far away from people.” He participated intellectually in the first four meetings he attended, but was frightened by the other members’ expressions of emotion. When a group member monopolized the entire fifth meeting with a repetitive, tangential discourse, he was enraged with the monopolizer, as well as with the rest of the group members for their complacency in allowing this to happen. With no warning, he abruptly terminated therapy. Other clients experienced a constant, pervasive dread of self-disclosure that precluded participation in the group and ultimately resulted in their dropping out. Still others engaged in premature, unconstrained self-disclosure and abruptly terminated. Some clients made such inordinate demands on their fellow group members for immediate, prefabricated intimacy that they created a nonviable group role for themselves. One early dropout unsettled the group in her first meeting by announcing to the group that she gossiped compulsively and doubted that she would be able to maintain people’s confidentiality. Clients with severe problems in the area of intimacy present a particular challenge to the group therapist both in selection and in therapeutic management (to be considered in Chapter 12). The irony is that these individuals are the very ones for whom a group experience could be particularly rewarding. Therefore, these clients, whose life histories are characterized by ungratifying interpersonal relationships, stand to profit much from an intimate group experience. Yet, if their interpersonal history has been too deprived, they will find the group threatening and may drop out of therapy more demoralized than before.46 > Jake, a fifty-eight-year-old single man, believed that the group was very helpful to others but not to him. He declared that he was just much less interested in relationships than the others in the group. He had been in foster care throughout much of his childhood, shuttled from one family to another and, as an adult, he believed relationships were always motivated by self-interest. Despite Jake’s regular attendance and our (ML) apparent agreement about his core issues, little progress was made. Though the group continued to be encouraging and respectful, Jake, after several months, wished the group well and left. Later, in a state of some desperation, he asked for a referral to individual therapy, which ultimately proved more helpful. << Recent research demonstrates that clients with dismissive and avoidant attachment styles are challenging in groups. They are self-reliant, resist the pull of belonging, and mistrust the care provided by others.ii At the least, it takes more time for them to engage with others in the group.47 Highly resistant and reactive clients will challenge the therapist’s authority and require respect for their pace and their need for autonomy.48 Personality inventories also provide helpful information. Clients who are highly distressed and experience high levels of shame, for instance, are vulnerable to dropping out. They stand in contrast to those who score high on measures of extraversion and conscientiousness, who are more likely to commit themselves to the work of group therapy.49 Clients who crave social connectedness but are hampered by poor interpersonal skills are particularly prone to psychological distress. They are frustrated by being in a group rich with opportunities for connectedness that they cannot make use of. Though they may report high levels of cohesion in the group, they continue to feel they are on the outside looking in—akin to the old sailor’s adage of “water, water everywhere but not a drop to drink.” It is of course the individual’s personal sense of belonging rather than group scores of high cohesion that best predicts outcome.50 Thus, clients with problems in intimacy represent both an indication and a potential contraindication for group therapy. The problem is twofold: how to identify and screen out those who will likely be overwhelmed in a group, and how to identify those who will likely succeed in a group. Both can be difficult to predict from the pregroup assessment alone. Individuals with narcissistic pathology or a pervasive dread of self-disclosure may be unfavorable candidates for interactional group therapy. But if such individuals are dissatisfied with their ability to relate, express a strong motivation for change, and manifest curiosity about their inner lives, then they warrant a trial of group therapy. Keep in mind, however, that such interpersonal defenses as withdrawal, devaluation, or self-aggrandizement may push such individuals into dysfunctional group roles.51 Tailored pregroup preparation can mitigate the risk of an early dropout. (We discuss preparation at length in Chapter 9.) Even greater caution should be exercised when the therapist adds a replacement member to an already established, fast-moving group. Often, combining individual and group therapy may be necessary to launch or sustain vulnerable clients in the group.52 Fear of Emotional Contagion and Other Factors. We have discussed the most prominent factors contributing to premature termination and will now examine other relevant factors. Several clients who dropped out of group therapy reported being adversely affected by hearing the problems of the other group members, as though emotional distress were contagious. This is a prominent concern and is the reason that some clients prefer individual therapy over group therapy.53 One man stated that during his three weeks in the group he was very upset by the others’ problems, dreamed about those problems every night, and relived them during the day. Other clients reported being upset by a particularly disturbed client in each of their groups. They were all frightened by seeing aspects of the disturbed client in themselves and feared that such exposure would evoke a personal regression. These are often individuals with a vulnerable sense of self and permeable ego boundaries. A fear of emotional contagion, unless it is extremely marked and clearly manifest in the pretherapy screening procedure, is not a particularly useful reason either to select or to exclude a client for group therapy. Therapists who are sensitive to the problem can deal with it effectively in the therapeutic process. Occasionally, clients must gradually desensitize themselves. We have known individuals who dropped out of several therapy groups but who persevered until they were finally able to remain in one. The therapist may help by clarifying for the client the crippling effects of his or her attitudes toward others’ distress. How can one develop friendships if one cannot bear to hear of another’s difficulties? If the discomfort can be contained, the group may well offer the ideal therapeutic format for such a client. The other reasons for group therapy dropouts—inability to share the therapist, complications of concurrent individual and group therapy, early provocateurs, problems in orientation to therapy, and complications arising from subgrouping into smaller cliques that may fragment the larger group—generally resulted from faulty therapeutic technique and will be discussed in later chapters. Sometimes, though, these problems arise neither solely from poor selection nor from faulty therapy technique, but from incorrect assumptions and misunderstandings about how group therapy works. For example, some clients who terminated because of an inability to share the therapist never relinquished the notion that progress in therapy was dependent solely on the amount of goods (time, attention, and so on) they received from the group therapist. One group member was preoccupied with the basic arithmetic of group therapy: “There are nine of us and ninety minutes—so we each get ten minutes—how much value can that be?” Some dependent and authority-oriented clients are referred to group therapy with a covert aim: their individual therapists attempt to use a group to wean their clients from the individual therapy. Obviously, group therapy is not a modality to be used to facilitate the termination phase of individual therapy, and the group therapist should be alert to inappropriate client referrals. There are, however, times when the thoughtful addition of group therapy to an individual treatment aimed at diluting a client’s dependence on the individual therapist is an excellent choice, and group and individual work can proceed concurrently. As we saw in earlier chapters, there is compelling evidence that the strength of the therapeutic alliance predicts therapy outcome.54 The failure to secure a strong alliance warrants therapist self-examination: this failing should not be ascribed to the client alone.55 A study of ten dropouts noted that several had been inadequately prepared for the group or misunderstood their referral to a group.56 No clear set of goals had been formulated, and some clients were suspicious of the therapists’ motives, questioning whether they had been placed in the group simply because the group needed a warm body. Some were wounded by being placed in a group with significantly dysfunctional members, taking this as a statement of the therapist’s judgment of their condition. Some were wounded simply by being referred to a group at all, as though they were being reduced from a state of specialness to a state of ordinariness. CRITERIA FOR INCLUSION Group trainees observing a heterogeneous interpersonal group always ask the same questions: Who should be referred to group therapy? How did the people we just observed get into this group? An obvious clinical criterion for inclusion is client motivation.57 The client must be highly motivated for therapy in general and for group therapy in particular. Group therapy is neither simple nor easy; motivation is essential. It will not do to start group therapy just because one has been sent—whether by a spouse, a probation officer, an individual therapist, or an agency. Many erroneous prejudgments of the group may be corrected in the preparation procedure, but if you discern in the interview, or see in the client’s responses on selection questionnaires, a deeply rooted aversion to entering a group, you should not accept that person as a member.58 Most clinicians agree that an important criterion for inclusion is significant problems in the interpersonal domain: for example, loneliness, shyness, social withdrawal, inability to be intimate, abrasiveness, issues with authority, narcissism, obsequiousness, dependency, feelings of unlovability, or a continuous need for admiration. Once we identify a key problematic interpersonal area in a client, an interesting question arises: Do we employ a therapy that avoids or addresses that area of vulnerability? We do not have firm group therapy research to guide us in answering this question. But we can draw some inferences from a large National Institute of Mental Health (NIMH) study of time-limited individual therapy in the treatment of depression. This study concluded that individuals need some interpersonal competence to make use of an interpersonal therapy.59 It is also helpful if prospective group clients can appreciate the interpersonal core of their difficulties. That alignment will strengthen the therapeutic alliance.60 Some clinicians suggest group therapy for clients who do not work well in individual therapy because of their limited ability to be accountable for their conduct or to report accurately on events in their lives (because of blind spots or because of ego-syntonic character pathology).61 Louis Ormont described the value of group therapy for many clients who are challenging in individual therapy and may benefit from the group members’ provision of multiple sources of feedback and interpretation.62 Impulsive individuals who tend to act immediately on their feelings often work better in groups than in individual therapy.63 The therapist working with these clients in individual therapy often finds it difficult to remain both participant and observer, whereas in the group these two roles are divided among the members: some members may, for example, rush to battle with the impulsive client, while others act as disinterested, reliable witnesses, whose testimony the impulsive client is often far more willing to trust than the therapist’s. In cases where interpersonal problems are not paramount (or not obvious to the client), group therapy may still be the treatment of choice. For example, clients who persistently intellectualize as a defense against feeling may do better with the affective stimuli available in a group. Other clients fare poorly in individual therapy because of severe problems in the transference: they may not be able to tolerate the intimacy of the dyadic situation and need the reality testing offered by other group members to make therapy possible. Others are best treated in a group because they characteristically elicit strong negative countertransference from an individual therapist.64 > George, a thirty-eight-year-old man referred to group therapy by his female individual therapist, struggled with his anger and his avoidance of tenderness or dependence that he traced back to the physical abuse he suffered at the hands of his brutal father. (George was also described in Chapter 2 [“Attack First”].) When his young son’s physical playfulness and roughhousing became frightening to him, he sought individual therapy because of his concern that he, too, would become an abusive father.

At first the individual therapy progressed well, but soon his therapist became uneasy with George’s crude and aggressive sexual declarations to her. She became particularly concerned when George suggested that he could best express his gratitude to her through sexual means. Stymied in working this through, yet reluctant to end the therapy because of George’s other gains, the therapist referred him to a therapy group, hoping that the concurrent group and individual format would clarify and dilute the intensity of the transference and countertransference. The group provided both support and challenge, and George’s treatment was able to proceed effectively in both venues. << Many clients seek therapy without an explicit interpersonal complaint. They may cite the common problems that propel the contemporary client into therapy: a sense of something missing in life, feelings of meaninglessness, diffuse anxiety, anhedonia, identity confusion, mild depression, self-derogation or self-destructive behavior, compulsive workaholism, fears of success, or alexithymia.65 But if one looks closely, each of these complaints has its interpersonal underpinnings, as we have noted. Each generally may be treated as successfully in group therapy as in individual therapy if the client can appreciate the value of the interpersonal group approach.66 Research on Inclusion Criteria Any systematic approach to defining criteria for inclusion must emerge from the study of successful group therapy participants. Though this is difficult research to conduct, there have been advances in our understanding of who is likely to benefit from group therapy. Those likely to succeed represent the mirror image of the dropouts we have just reviewed.67 But at times it can be difficult to discern who is progressing and who is failing in the group. Obtaining feedback from clients via outcome and process questionnaires can be very helpful in this regard.68 A study of forty clients in five outpatient therapy groups through one year of group therapy aimed to identify factors evident before group therapy that might predict successful outcomes. Outcomes were evaluated and correlated with many variables measured before the start of therapy. None of the pretherapy factors that had been measured predicted success in group therapy, including level of psychological sophistication, therapists’ prediction of outcome, previous self-disclosure, and demographic data. However, two factors measured after the sixth and twelfth meetings did predict success one year later: the clients’ attraction to the group and the clients’ general popularity in the group.69 The finding that popularity correlated highly with a successful outcome has some implications for selection, because researchers have found that high self-disclosure, activity in the group, and the ability to introspect were some of the prerequisites for group popularity.70 Members who help a group achieve its goals gain popularity and status.71 These findings underscore the value of including in each group some members whose openness promotes group interaction and makes it safer for all to take risks. More recent research corroborates these findings.72 The psychologically “rich” get richer in therapy, and one way to help the “poor” get rich is by having them participate in groups with these kinds of successful group members. Early encounter group studies reported similar findings. Those who profited most from encounter groups were people who highly valued and desired personal change, who had high expectations for the group, who viewed themselves as deficient both in understanding their own feelings and in their sensitivity to the feelings of others, and who anticipated that the group would provide relevant opportunities for communication and help them correct their deficiencies. When these attitudes were linked with a willingness to take risks in the group, the individual’s group work flourished.73 The finding that positive expectation predicts favorable outcome has substantial research support: The more a client expects therapy—either group or individual—to be useful, the more useful will it be.74 As we have noted, group therapy is a challenging therapy for an individual’s first therapeutic encounter. The role of prior therapy is important in this regard: experienced clients have more positive and more realistic expectations of therapy. Agreement between therapist and client about therapy expectations strengthens the therapeutic alliance.75 Not only is this an important selection issue, but it reminds us that pregroup preparation should help to create positive client expectations. The Client’s Effect on Other Group Members Unlike individual therapy recruitment, where we need consider only whether the client will profit from therapy and whether he or she and a specific therapist can establish a working relationship, recruitment for group therapy cannot, in practice, ignore the other group members. Recent group dynamics research identifies this mutual member impact—for better and for worse—as the actor-partner interdependence.76 As we compose a group or add members to an existing one, we must consider how the new client will respond to the particular others who are already in the group, and they to him or her. There may also be clients who would do well in a variety of treatment modalities but are placed in a group to meet some specific group needs. For example, some groups at times seem to need an aggressive member, or a strong male, or a more tender member. While clients with borderline personality disorder often have a stormy course of therapy, some group therapists intentionally introduce them into a group because of their beneficial influence on the group therapy process. Generally, such individuals are more in touch with their unconscious, less inhibited, and less dedicated to social formality than most people, and they may lead the group into a more candid and intimate culture. Considerable caution must be exercised, however, in including a member whose ego strength is significantly less than that of the other members. If these clients have socially desirable behavioral traits, they may be valued by the other members because of their openness and deep perceptivity, and will generally do very well. If, however, their behavior alienates others, they may impede the group; they will be driven into a deviant role and will likely have a countertherapeutic experience. The Group Therapist’s Feeling Toward the Client One final, and important, criterion for inclusion is the therapist’s personal feeling toward the client. Regardless of the source, the therapist who strongly dislikes or is disinterested in a client (and cannot understand or alter that reaction) should refer that person elsewhere.77 This caveat is obviously relative, and you must establish for yourself which feelings would preclude effective therapy. It is our impression that this issue is somewhat more manageable for group therapists than for individual therapists. With the consensual validation available in the group from other members, and potentially from one’s co-therapist, many therapists find that they are more often able to work through initial negative feelings toward clients in group therapy than in individual therapy. As therapists gain experience and self-knowledge, they usually develop greater generosity and tolerance and find themselves actively disliking fewer and fewer clients. SUMMARY: CLIENT SELECTION Selection of clients for group therapy is, in practice, a process of deselection: group therapists exclude certain clients from consideration and accept all others. Although empirical outcome studies, selection aids, and clinical observation have generated inclusion criteria, the study of failures in group therapy, especially of clients who drop out early in the course of the group, provides important exclusion criteria. Clients should not be placed in a group if they are likely to fail at the main group tasks of self-exploration, self-disclosure, and care and respect for the group and its members, whether the cause is logistical, practical, motivational, or due to a lack of psychological-mindedness. Clients should be excluded from a heterogeneous, interpersonal group if they are in the midst of a life crisis that can be more efficiently addressed in brief, problem-specific groups or in other therapy formats. Clients whose care requires a high degree of clinical management should have their entry deferred until the crisis has become sufficiently manageable to permit consistent group participation. Conflicts in the sphere of intimacy represent both indication and contraindication for group therapy. Group therapy can offer considerable help in this domain—but if the conflicts are too extreme, the client will choose to leave (or be extruded by) the group. The therapist’s task is to select those clients who are as close as possible to the border between need and impossibility. If no markers for exclusion are present, the vast majority of clients seeking therapy can be treated effectively in group therapy. GROUP COMPOSITION We now shift our focus from selecting group therapy members to composing therapy groups. Group composition principles complement the earlier guidelines for group selection: both also inform our work in pregroup preparation (see Chapter 9). Although we address these areas separately, they are clinically very much interwoven. We shift from a focus on who is suitable for group therapy in general to a discussion of individual suitability for a particular group. Moreover, we believe that the principles of group composition are relevant in all therapy groups, even the most structured and seemingly homogeneous groups. If therapists fail to attend to issues of diversity in interpersonal, cognitive, personality, attachment, and ethnoracial and cultural dimensions, they will fall prey to a simplistic and ineffective “one-size-fits-all” approach to group therapy.78 Let’s begin by imagining these two scenarios: 1. Intake coordinators wish to form three new therapy groups and have selected twenty-one clients whom they believe will benefit from group therapy. But how to assign clients to the three groups? 2. An intake coordinator considers a client to be a suitable candidate for group therapy, and there are several groups operating in the clinic, each with one vacancy. Which group would offer the best fit for that particular client? Both situations raise similar questions: Will the proper blend of individuals form an ideal group? Will the wrong blend fail to coalesce into a working group? Is there an evidence-informed, superior method of composing a group? In the next few pages, we discuss the current state of knowledge about composing therapy groups. As in preceding chapters, we will focus our attention particularly on heterogeneous groups with ambitious goals that focus on here-and-now member interaction. Let us begin with a cautionary note: human behavior and human interaction is so complex that our answers to these questions should be considered as tentative: they are a work in progress. And yet, keep in mind that the stakes are high. Errors in forming a group or introducing a group member into an ongoing group affect not only the new member but all the group members. Furthermore, the constraints of closed, time-limited groups leave little opportunity to correct group composition errors. Group therapists struggle to compose a group with the right blend of clients. But what do we mean by right and wrong “blends”? Blends of what? Which of the infinite number of human characteristics are germane to the composition of an interactional therapy group? Since each member must continually communicate and interact with the other members, we must hope for a blend that allows members to interact in a manner that maximizes engagement with one another and promotes interpersonal learning. The entire procedure of group composition and selection of group members is thus based on the important assumption that we can, with some degree of accuracy, predict the interpersonal or group behavior of an individual from our pretherapy screening and assessment. But are we able to make that prediction? THE PREDICTION OF CLIENT BEHAVIOR IN THE GROUP Earlier in this chapter, we advised against including individuals whose group behavior would render their own therapy unproductive and impede the therapy of the rest of the group. Generally, predictions of the group behavior of individuals with extreme and fixed maladaptive interpersonal behavior or extreme deficits in interpersonal function are reasonably accurate: In general, the more profound the pathology, the greater the predictive accuracy. However, in everyday clinical practice, the problem is far more subtle than this general rule may suggest. Most clients who seek treatment have a wide repertoire of behavior, and their ultimate group behavior can be difficult to predict. We’ll begin by examining the most common procedures used to predict behavior in the group. The Standard Diagnostic Interview The most common method of screening clients for groups is the standard individual interview, in which the interviewer explores the reasons for seeking therapy as well as environmental stresses, personal history, cultural factors, physical health, and prior mental health treatments.79 One of the traditional end products of the mental health interview is a diagnosis that, in capsule form, is meant to summarize the client’s condition and convey useful information from practitioner to practitioner. Ideally it should also offer an explanatory formulation that leads to a comprehensive treatment plan. But does it succeed in offering practical information relevant to group therapy? Group therapists will attest that it generally does not! Psychiatric diagnoses based on standard classificatory systems—for example, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—are of limited value as an indicator of interpersonal behavior.80 Traditional diagnostic nomenclature was never meant for this purpose; it stemmed from a disease-oriented medical discipline based on aggregates of certain signs and symptoms. Personality has generally been classified in a similar fashion, emphasizing discrete categories of interpersonal behavior. Overall, the standard intake interview has been shown to have little value in predicting subsequent client in-group behavior.81 That a diagnostic label fails to predict much about human behavior should neither surprise us nor cause chagrin. No label or phrase can adequately encompass an individual’s essence or entire range of behavior.82 Any limiting categorization is not only erroneous and stigmatizing, but offensive, and stands in opposition to the basic human foundations of the therapeutic relationship. In our opinion, during the process of psychotherapy, the less we think in terms of diagnostic labels, the better. (Albert Camus once described hell as a place where one’s identity was eternally fixed and displayed on personal signs: Adulterous Humanist, Jittery Philosopher, Charming Janus, and so on.83 To Camus, hell is where one has no way of explaining oneself; where one is fixed, classified—once and for all time.) The Interpersonal Intake Interview If our aim is to make better use of the initial interview, then the interview should focus on the client’s relationships. The interviewer should explore the client’s interpersonal and group experiences, including earliest relationships, long-term friendships, and the degree of intimacy experienced with people of both genders. How do relationships typically start? How do they end? It is often fruitful to ask for a detailed description of a typical twenty-four hours, taking particular note of how the client’s life is peopled. With whom are they close? How often does the client’s cell phone ring? Who texts them? How do they use social media? Moving beyond the history, we encourage turning attention to the process of the interview itself, which offers information about the client’s ability to deal with the interpersonal here-and-now interaction of a group. Is the client able to comment on the process of the intake interview, or to understand and accept the therapist’s process commentary? For example, is the client obviously tense, but denies it when the therapist asks? Is the client able and willing to identify the most uncomfortable or pleasant parts of the interview? Can the client reflect on the experience of being emotional in the interview? Or comment on how he or she wishes to be thought of by the therapist? Or check out what the therapist is thinking? All these observations can help to predict the client’s in-group behavior. The predictive power of this type of interview has yet to be determined empirically, but it seems far more relevant to subsequent group behavior than does the traditional clinical intake interview.84 Contemporary psychotherapists examine the client’s pathogenic beliefs and expectations about relationships, which give form to the client’s interpersonal behavior. The following vignette illustrates how therapists’ attention to their own emotional responses to the client anticipates how the client is likely to interact in the group: > Connie, a woman in her forties, was referred by her family physician for group therapy because of her social anxiety, dysthymia, and interpersonal isolation. Immediately on entering the office, she told me (ML) she had a “bone to pick” with me. “How could you leave a message on my answering machine calling me ‘Connie’ and yourself ‘Dr. Leszcz’? Don’t you understand the power imbalance that promotes? Haven’t you heard of feminism and empowerment? Do you treat all the women you know like this, or only your clients?”

I was at first jolted and a bit irritated, but after a few moments’ reflection, I considered that she indeed had a point, and I apologized for the wording of my message.

Later in the session, as we developed rapport, I returned to her anger about my phone message. She described feeling regularly devalued and bulldozed into silence. It reminded her of the way her father and her ex-husband had treated her.

“So how did you feel about my response to your anger?” I asked.

“A bit surprised. Almost shocked. I’m not used to apologies from men.”

This gave us a useful interpersonal behavior forecast for the group. I suggested to Connie that she may be inclined initially to relate to the group members in the same way that she did with me, but she did have a choice. She could make the group experience yet another in a series of angry disappointments, or she could engage a process of learning and understanding that could interrupt this interpersonal sequence. << The Client’s Prior Group Therapy History What is the most powerful method of predicting an individual’s group behavior? It is to observe that individual engaged in a task closely related to the group therapy situation. In other words, the closer we can examine individuals in an activity closely approximating the therapy group, the more accurately we can predict their in-group behavior. Thus, the client’s history of prior group experiences may be of significant value. Some clients will move along a continuum of group treatments that may include psychiatry inpatient groups, day treatment, or addiction groups. A careful inquiry into their experiences in these groups may be illuminating and help the therapist foresee potential challenges. The client’s capacity to engage and to disclose personal information early on in a prior group therapy bodes well and suggests a readiness to trust.85 One possibility for assessing clients who do not have prior group experiences is via very brief training groups. Research on very brief groups established for clients who were on a waiting list for formal group therapy indicates that these groups were well received by clients, served to prepare them for the group to follow, and reliably predicted their subsequent group behavior.86 In one well-designed project, thirty clients on a group therapy waiting list were placed into four one-hour training sessions. The sessions were all conducted according to a single protocol, which included an introduction to here-and-now interaction. The researchers found that each client’s participation in the training sessions correlated with his or her subsequent behavior during the first sixteen group therapy sessions. Similar findings were reported in another, larger project.87 For practitioners or clinics facing time or resource pressures, however, the use of trial groups may be an intriguing but highly impractical idea. Specialized Diagnostic Procedures Easy to use and free self-report questionnaires that capture attachment, interpersonal, and coping styles are readily accessible to supplement clinical assessment of the client’s way of relating to and engaging others.88 Evaluating interactional tendencies more accurately can improve our methods of matching clients to groups and anticipating how they will affect and experience their groups.89 If the critical variable in group therapy selection is interpersonal in nature, why not develop an interpersonally based diagnostic scheme? An Interpersonal Nosological System The advent of the object-relations and interpersonal systems of conceptualizing psychopathology, together with the increase in the number of people seeking treatment for less severe problems in living, has stimulated more sophisticated attempts to classify individuals according to a host of interpersonal styles of relating.90 Attachment Style There is an increasing amount of clinical and research focus on the nature and ramifications of an individual’s attachment style.91 John Bowlby’s seminal work on relationship attachment categorizes individuals on the basis of four fundamental styles: (1) secure; (2) insecure-anxious; (3) insecure-detached, or dismissive and avoidant; and (4) insecure-fearful.92 It is important for group therapists to recognize attachment styles because they have predictive value regarding clients’ group behaviors. We can assess client attachment by looking at the client’s history and experience of relationships and by using self-report questionnaires.93 Clients with secure attachment do well in almost all therapy groups. They seek connection and can tolerate frustration. In contrast, group members with attachment insecurity may struggle in the group. Anxiously attached clients will be hungry for connection and apprehensive about its reliability. Group members with attachment avoidance are dismissive of human connections and slow to warm up. The insecure, fearful client may be overwhelmed by the demands for relationships in the group. All three varieties of insecurely attached clients can generate challenges in the development of group cohesion. Although insecurely attached clients can benefit from group therapy, they will engage with the group very differently from securely attached ones. The closeness that might be welcomed by the anxiously attached client may be challenging and even overwhelming to the avoidant, dismissive client. The anxiously attached individual tends to amplify emotional signals, seeking evidence of group members’ and the therapist’s responsiveness. In contrast, the dismissively attached individual minimizes any signs of distress and is disinterested in engagement with others. Hence, the dismissively attached individual may fare better in a mature group, where the slowness to engage may be better accommodated without negatively impacting the group’s cohesion, than in a newly formed group. Although groups that have members with heterogeneous attachment styles are likely to be most effective, we still have more to learn about whether groups should be more or less homogeneous on these attachment dimensions.94 Attending to attachment style can be very instructive at all phases of the group therapy trajectory, starting with the pregroup assessment. By identifying prominent attachment factors, we may be able to anticipate potential problems and tilt things in a positive direction. > Anne, a sixty-year-old single woman, was referred by her family doctor for an evaluation for group therapy. She worked in IT, lived alone, and felt safe in her solitude. She described herself as “friendly enough” at work, and she made token appearances at office social functions, eagerly counting down the time until it was acceptable to leave. She was an expert at escape behaviors. She had recently dislocated her shoulder, however, and her struggle coping with that injury forced her to confront her extreme social isolation. She became frightened: without friends, social groups, or anyone to call for help, she realized she had to change and sought therapy.

Anne reported no other emotional distress. Of note, she had once had a severe drinking problem, for which she had been successfully treated in residential care twenty-five years earlier. She had had two courses of individual therapy for several years each when she was in her forties, but had little good to say about either therapy or therapists. She acknowledged growing up with a terrifying and emotionally abusive father. She had not been physically or sexually abused, but that threat always loomed large, and it had led her to adopt a defensive policy of “keep my head down and my mouth shut,” which she did with great expertise.

The results of Anne’s self-report questionnaires confirmed the clinical picture: Anne was a person with a strongly dismissive, avoidant attachment style. She had experienced significant early life adversity, and she now regarded relationships as dangerous and not worth the risk of engagement.

After I (ML) shared my formulation and impressions, Anne expressed particular interest in the traumatic roots of her difficulties. Although she did not have symptoms of psychological trauma in the form of flashbacks, intense anxiety symptoms, or hyperarousal, she showed significant interpersonal consequences of early life exposure to physical threat and emotional abuse. At the same time, she recognized that the isolation was unhealthy for her over the long term, and she acknowledged fears of returning to alcohol. She was eager to learn, and her motivation for engagement in group therapy seemed to build as we were able to focus on how group therapy worked.

What seemed most helpful to Anne was understanding that the group would be a safe, cohesive environment and would be led by able therapists who would allow her to proceed at a pace that felt safe. The objective of her group work would be to liberate herself from the fear engendered by her father that had influenced all her relationships. The group would aim to increase her zone of safety in relationships, first within the group and then hopefully outside the group. We talked as well about her propensity to distance herself in relationships, acknowledging that the risk for her would be to dismiss others in the group or flee when afraid. In contrast, I noted that her openness and her risk-taking with me boded well for her participation in group therapy. << Interpersonal and Personality Inventories Contemporary interpersonal theorists have attempted to develop a classification of diverse interpersonal styles and behavior based on data gathered through interpersonal inventories (often, the Inventory of Interpersonal Problems—IIP).95 The client’s responses are placed onto a schematic circumplex of interpersonal relations that portrays the client’s tendencies to relate along two key intersecting interpersonal dimensions: control, ranging from domineering to nonassertive/submissive, and affiliation, ranging from warm and overly nurturant to cold (see Figure 8.1).96 Two early studies that used a form of the interpersonal circumplex in a twelve-session training group of graduate psychology students found that hostile, dismissive members were much more likely to experience other group members as hostile. Strongly dominant (domineering) individuals resisted group engagement and tended to devalue or discount the group.97 Subsequent research reinforces these findings. Clients who tend to seek affiliation generally engage well in group therapy, but the pleasure of belonging is not an end in itself and must be utilized to increase the client’s risk-taking within the group.98 Individuals who are dominant and cold typically are more difficult to engage, but interesting work by the group analyst Steiner Lorentzen and colleagues has demonstrated that with proper pregroup preparation and active, supportive group leaders, these dismissive and hard-to-engage clients can do well, even in time-limited interactional group treatments.99 A longer course of treatment may be required for clients with this interpersonal profile to become less defensive and more trusting.100 Here again, we see the value of these findings as a clinical alert that can increase the group leader’s attention to the impact of clients’ attachment and interpersonal styles on the group. The group leader can also review these findings with the client, determine if they resonate with the client, and utilize the information to inform the client’s therapeutic goals and tasks.101 A further illustrative example of this type of research is found in the well-constructed studies by William Piper, John Ogrodniczuk, and colleagues that tested the comparative effectiveness of two kinds of group therapy and the effects of clients’ personality traits on the results.102 The researchers randomly assigned clients seeking treatment for loss and complicated grief to either a twelve-session interpretive/expressive group therapy, which aimed at depth psychological exploration, or a much more supportive group therapy. Client outcome assessments included measures of depression, anxiety, self-esteem, and social adjustment. Before therapy, each client was given the NEO-Five Factor Inventory (NEO-FFI), which measures five personality variables: neuroticism, extraversion, openness, conscientiousness, and agreeableness.103 What did the study find? Both group therapies were demonstrably effective, although the interpretive group generated much greater affect and anxiety among the group members. Personality features carried much impact: neuroticism predicted poorer outcome in both types of groups; extraversion, conscientiousness, and openness predicted positive outcomes in both groups; and the fifth factor, agreeableness, predicted success in the interpretive/expressive group therapy but not in the supportive group therapy. Clients who score high on the agreeableness factor make others feel welcome and safer in the group and help strengthen group members’ sense of belonging. Two other personality measures relevant to group therapy outcome have also been studied by this research team: Psychological-Mindedness 104 and the Quality of Object Relations (QOR) Scale.105 Both of these measures have the drawback of requiring that the client participate in a thirty- to sixty-minute semistructured interview instead of a client self-report. Psychological-mindednessiii predicts good outcome in all forms of group therapy. Psychologically minded clients are better able to work in therapy—to explore, reflect, and understand.106 Clients with higher QOR scores (i.e., greater maturity in their relationships) are more likely to achieve positive outcomes in interpretive/expressive, emotion-activating group therapy. These clients are also more trusting and able to express a broader range of negative and positive emotions in the group. Clients with low QOR scores are less able to tolerate this more demanding form of therapy and do better in supportive group formats that do not seek to activate distressing emotions.107 Hence there is good evidence that placing clients with very poor relationship capacity into very active and dynamic groups, in the hope that they will benefit from the exposure in the group, is often unsuccessful for the client and has an inhibiting impact on the group. SUMMARY: PREDICTING CLIENT BEHAVIOR Of all the methods used to predict a member’s behavior in a therapy group, the traditional individual intake interview oriented toward establishing a diagnosis is the most limited in its accuracy even though it is the most commonly used. We can enhance its utility, however. Keep in mind that the more the intake procedure resembles the here-and-now focus of the group situation, the more accurate the interviewer’s prediction of a client’s behavior becomes. Hence we recommend that group therapists modify their intake interview to focus on the client’s interpersonal functioning. PRINCIPLES OF GROUP COMPOSITION How do we apply our insights from individual client assessment to the project of composing a group? Group composition is still a soft science. But predictions of how each of our clients is likely to experience the group and of how others will likely experience them in the group helps group therapists to construct more effective groups. Some key findings to consider in composing intensive interactional psychotherapy groups emerge from the empirical and clinical literature and are summarized here: • Clients will re-create their typical relational patterns within the microcosm of the group. This is the essential therapeutic opportunity, and clients should not be discouraged by—but even welcome—the times when their core difficulties emerge in the group. • Clients require a certain amount of interpersonal competence to make the best use of interactional group therapy. • Psychologically minded clients contribute substantially to an interactional therapy group. • Personality and attachment variables are more important predictors of a client’s behavior in a group than diagnosis alone. • We can augment our clinical evaluations with simple, validated questionnaires that add to our understanding of our clients’ ways of interacting. • We can anticipate these interpersonal patterns and address them in pregroup preparation. • Members eager for engagement and willing to take social risks will advance the group’s work. • Clients who are securely attached typically do well in group therapy and promote cohesion. • Clients who are rigidly domineering or dismissive of others may impair the work of the therapy group. This is a cautionary note and not a prohibition, as this risk can be offset by good preparation, therapist flexibility, and empathy. • Clients who have an insecure attachment style will engage in the group in contrasting ways. Some will be anxiously eager for connection and others dismissive and distancing. • Clients who are more rigid, less trusting, and less cooperative will likely struggle with interpersonal exploration and feedback and may require more supportive groups that build communication and coping skills without generating emotional distress. • Clients with high degrees of neuroticism will likely require a longer course of therapy to effect meaningful change in symptoms and functioning. We return now to our important question: Given ideal circumstances—a large number of client applicants and a wealth of information by which we can predict behavior—how then to compose the therapy group? There is no doubt that composition affects the character and process of the group, but the actual mechanism of influence has eluded full clarification.108 At the same time, it is clear that composition is not equivalent to destiny. It is instructive to keep in mind that the therapist’s skill can offset problematic and challenging relational styles among clients.109 We have had the opportunity to study the conception, birth, and development of more than 350 therapy groups—our own and our students’—and have been struck repeatedly by the fact that some groups seem to jell immediately, some come together more slowly, and others founder painfully or fail entirely. It also seems clear that the jelling and success of a group is only partly related to the competence or efforts of the therapist or to the number of “good” members in the group. To a degree, the critical variable is some as yet unclear blending of the members. A clinical experience many years ago vividly crystallized this conclusion for me (IY). I was scheduled to lead a six-month experiential group of clinical psychology interns, all at the same level of training and approximately the same age. At the first meeting, over twenty participants appeared—too many for one group—and I decided to split them into two groups. I asked the participants simply to move in random fashion around the room and talk to one another and, after five minutes, to form two equal-sized groups. Thereafter, each group met for ninety minutes, one group immediately following the other. Although the members of the two groups had much in common, it was immediately apparent that the two groups were radically different. One group assumed an extraordinarily dependent posture. In the first group meeting, I arrived on crutches with my leg in a cast because I had injured my knee in an accident a couple of days earlier. Yet the group made no inquiry about my condition. Nor did they themselves arrange the chairs in a circle. ( (Remember that all were mental health professionals, and most had led therapy groups!) They asked my permission for such mundane acts as opening the window and closing the door. Most of the group life was spent analyzing my aloofness and coldness and their fear of me. In the other group, I was only halfway through the door before several members asked, “Hey, what happened to your leg?” The group moved immediately into hard work, and each of the members used his or her professional skills in a constructive manner. In this group I often felt redundant to the work and occasionally inquired about the members’ disregard of me. This “tale of two groups” illustrates how the makeup and composition of groups dramatically influence the character of the subsequent group work. If these groups had been ongoing rather than time limited, the different environments they created might eventually have made little difference in the beneficial effect each group had on its members. In the short run, however, the members of the first group felt more tense, more deskilled, and more restricted. Had it been a therapy group, some members of this group might have felt so dissatisfied that they would have dropped out of the group. Another pertinent narrative occurred in a large encounter group study.110 Two short-term groups were randomly composed but had an absolutely identical leader: a tape recording that provided instructions about how to proceed at each meeting. Hence, any variance in group outcome could not be attributed to effects of leadership. Within a few meetings, two very different cultures emerged: one group was obedient and subordinate whereas the other group was irreverent. The members of the second group mocked the tape’s instructions and nicknamed the taped voice “George.” Not only did the two groups evolve different cultures, but they had very different outcomes. At the end of the thirty-hour group experience (ten meetings), the irreverent (less dependent) group had an appreciably better outcome. HOMOGENEITY OR HETEROGENEITY? It is generally accepted clinical wisdom that intensive interactional therapy groups with the ambitious goal of deep interpersonal learning and change are more effective if their members are homogeneous in ego strength and the capacity to tolerate strong emotions, but heterogeneous in areas of conflict and interpersonal concerns.111 Homogeneous groups, on the other hand, have many advantages if the therapist wishes to offer support for a shared problem or to help clients rapidly develop skills needed for symptomatic relief.112 Such groups jell more quickly, become more cohesive, offer more immediate support to group members, are better attended, have less conflict, and provide more rapid relief of symptoms. Homogeneous groups can be tailored for specific kinds of difficulties that would preclude an interactional group—for example, a skill-building group for individuals on the autism spectrum with Level 1 difficulties, many of whom may have been diagnosed previously as Asperger’s.113 Even with homogeneous groups, however, composition is not irrelevant. A seemingly homogeneous group for men with HIV, clients with Parkinson’s, or women with breast cancer will be strongly affected by the stage of illness of the members. An individual with advanced disease may ignite the other members’ greatest fears and lead to members’ disengagement or withdrawal.114 Even in highly specialized, manual-guided group therapies, such as groups for individuals dealing with a genetic predisposition to developing breast or colorectal cancer, the degree of member openness and capacity to care for one another will affect the group’s work.115 The issue becomes further clouded when we ask, “Homogeneous for what?” Age? Sexual orientation? Symptoms? Ethnoracial identity? Gender? Life developmental stage? Education? Socioeconomic status? Psychiatric diagnoses? Which of these variables are the critical ones? Is a group composed of women with bulimia, university students with social anxiety, or seniors with depression homogeneous because of the shared symptom, or heterogeneous because of the wide range of personality traits of the members? It is essential for the group leader to stay alert to these potential sources of difference and keep the uniqueness of each group member in mind. Homogeneous groups are most effective when the group leader does not homogenize the group members. Similarly, when we look at utilizing member heterogeneity to maximize interpersonal learning, we must avoid the hazard of creating an isolate or marginalizing an individual. S. H. Foulkes and E. J. Anthony, influential group analysts, suggested blending diagnoses and disturbances to form a therapeutically effective group.116 Consider the age variable: If there is one seventy-year-old member in a group of young adults, that individual may choose (or be forced) to personify the older generation. He or she may be stereotyped as the “transferential parent” and not seen as an authentic individual. A similar process may occur in an adult group with a lone late adolescent who assumes the unruly teenager role. Yet there are also advantages to having a wide age spread in a group. Most of our ambulatory groups have members ranging in age from twenty-five to eighty. Through working out their relationships with other members, they come to understand their past, present, and future relationships with a wider range of significant people: parents, peers, and children. The interaction between a seventy-five-year-old man working at repairing his relationship with his estranged daughter can be powerfully informed by a forty-year-old group member reconciling her relationship with her elderly, dying father. At the same time, it is important that members do not get locked into specific roles, whether they are roles they pursue or that the group projects onto them.117 We want the group to be a social microcosm, but one that is flexible rather than rigid. Ethnoracial, Cultural, and Gender Diversity Contemporary group leaders must pay great attention to group members’ sexual orientation, gender identity, cultural background, and ethnoracial factors. Our therapy groups should mirror our society and should model openness and acceptance to enhance in-depth exploration into members’ personal identities and desires.118 Group members from minority and racialized backgrounds will need reassurance that they will be seen and accepted as individuals and not as stereotypes. The group participants need to be alert to the risks of micro-aggressions—inadvertent or intentional slights and indignities rooted in societal bias and privilege. Therapists must be open to learning about each client’s personal sense of self in terms of sexual orientation identity and in ethnoracial and cultural terms.119 At times, some clients may actively avoid groups with members from their own ethnocultural background because of feelings of shame and fear of exposure within their larger community. At other times, as in the case of group therapy for veterans with posttraumatic stress disorder (PTSD), a powerful shared experience and the accompanying psychological sequelae can outweigh ethnoracial factors.120 What about gender and group composition? Some authors advocate single-gender groups. The group therapy research, however, does not strongly support this approach. Mixed-gender groups are clearly effective, though all-female groups may be indicated when issues of sexual abuse and shame are prominent.121 Gender dynamics and the intertwining of the political and the personal will likely emerge in mixed-gender groups, mirroring our contemporary environment. Therapy groups may reinforce gender stereotypes or challenge them, particularly around the dynamics of power, vulnerability, and tenderness.122 Women in general carry more positive attitudes toward group therapy than men.123 The presence of women in groups benefits the male group members. Men in all-male groups are often less intimate and more competitive than they are in mixed-gender groups, where they tend to be more self-disclosing and less aggressive. Unfortunately, the benefit of gender heterogeneity does not always accrue to the women in these groups: women in mixed-gender groups may become less active and more deferential to the male participants. Mixed-gender groups consisting of only one or two men and several women may result in the men feeling peripheral, marginalized, and isolated.124 A discussion of gender and group composition also reminds us that for many clients seeking group therapy, gender identity is nonbinary. Both trans and gender-nonconforming individuals need assurance that a safe space will exist in their groups for disclosure, exploration, and interaction. It is essential that their identity and preferred ways of being addressed are respected and honored in the group.125 GENERAL CLINICAL CONSIDERATIONS Groups do better if some members are advocates of constructive group norms. Placing one or two “veterans” of group therapy into a new group may pay large dividends. Leaders must attend to the fit and the timing of entry of a new member. A challenging, controlling, and devaluing client may very much need group therapy but may overwhelm a group early in its development. Such a client is more likely to succeed in a mature and cohesive group.126 We can sometimes predict that clients will fit poorly with a particular group at a particular time because of the likelihood that they will assume an unhealthy role in it. Consider this clinical illustration: > Alicia, a twenty-nine-year-old woman with prominent narcissistic personality difficulties, was evaluated for group therapy. She was professionally successful but interpersonally isolated, and experienced chronic dysthymia that was only partially ameliorated with antidepressants. When I (IY) saw her for a pregroup consultation, I experienced her as brittle, explosive, highly demanding, and devaluing of others. In many ways, Alicia’s difficulties echoed those of another woman, Lisa, who had just quit the group (thereby creating the opening for which Alicia was being evaluated). Lisa’s intense, domineering need to be at the center of the group, coupled with an exquisite vulnerability to feedback, had paralyzed the group members, and her departure had been met with clear relief by all. At another time, this group and Alicia could have been a constructive fit. So soon after Lisa’s departure, however, it was very likely that Alicia’s characteristic style of relating would trigger strong responses of “here we go again,” reawakening feelings that group members had just painfully processed. An alternative group for Alicia was recommended. << One additional clinical observation: As a supervisor and researcher, I (IY) had an opportunity to closely study an entire thirty-month course of an outpatient clinic group led by two effective psychiatric residents. The group was remarkably homogeneous in composition and consisted of seven members, all in their twenties. Six of them were identified at the time as having schizoid personality disorder. To observers the group seemed remarkably dull, slow, and plodding. And yet attendance was nearly perfect, and group cohesiveness extraordinarily high.127 Thorough evaluations of clinical progress were available at the end of one year and again at thirty months. The members of this group (both the original members and the replacements) did extraordinarily well and underwent both substantial characterological changes and significant symptomatic remission. This apparently homogeneous group, contrary to the clinical dictum, did not remain at a superficial level and effected significant personality changes in its members. Although the interaction seemed lumbering to the therapists and researchers, it did not to the participants. None of them had ever had intimate relationships, and many of their disclosures, though objectively unremarkable, were subjectively exciting first-time disclosures for them. What emerges from this illustration is the recognition that many so-called homogeneous groups remain superficial not because of homogeneity, but because of the psychological mindset of the group leaders and the restricted group culture they fashion. Therapists leading a group of individuals with a common symptom or life situation must be careful not to convey implicit messages that generate group norms of restriction, a search only for similarities, and discouragement of self-disclosure and differentiation. Norms, as we elaborated in Chapter 5, once set into motion, may become self-perpetuating and difficult to change. One other perspective on composition comes from the rare, but impossible-to-forget, experience of asking a client to leave a group. In our experience, over many years, many groups, and thousands of clients, this situation has come up only a handful of times. Invariably, the clients were asked to leave their group because their participation made the group unworkable. They made the group unsafe for others by attacking, shaming, and devaluing group members. They refused to be accountable for their impact, despite much feedback, and would double down on their attacks. In essence, these clients all assumed a similar rigid approach, stating, “I call it the way I see it and people are just being babies here.” There was no spirit of collaboration, and every therapeutic tactic employed was met with fierce resistance. The groups affected were literally withering over time, and the group leaders had no choice but to ask the offensive members to leave. In such instances the therapist still has clinical responsibility for the client and should offer a referral for further individual therapy in which the client may be able to process the events in the group. SUMMARY: GROUP COMPOSITION In our examination of the research and clinical literature about client selection and group composition, we are on much surer footing when discussing the selection of clients for group therapy than when discussing the composition of the therapy group. However, though there is no certainty about the best composition of groups, there are some instructive principles to guide us. Our approach to composition is informed by our understanding of the group’s tasks: First, we wish to capitalize fully on the group as a social microcosm—a miniature social universe in which members understand and improve their interactions with a variety of other individuals. Hence the group should resemble the real social universe, composed of members with varying interpersonal styles, conflicts, gender, occupations, cultural and ethnoracial backgrounds, ages, and socioeconomic and educational levels. Yet the group should be sufficiently homogeneous for its members to engage the demands of group therapy. It is a delicate balance. If the challenges are too great, and the staying forces (the attraction to the group) too small, the individual does not change but instead physically or psychologically leaves the group. On the other hand, if the challenge is too small, no learning occurs, members will collude, and exploration will be inhibited. Second, the group must be able to respond to members’ needs both for emotional support and for constructive challenge. On the basis of our current knowledge, therefore, we propose that cohesiveness be the primary guideline in the composition of therapy groups. Cohesive groups with higher engagement generally produce better clinical outcomes than noncohesive groups.128 Hence, group therapists must select clients with the lowest likelihood of premature termination. Individuals with a high likelihood of being irreconcilably incompatible with the prevailing group ethos and culture should not be included in the group. It bears repeating that group cohesiveness is not synonymous with group comfort or ease. Quite the contrary: it is only in a cohesive group that conflict can be tolerated and transformed into productive work. Thus, we advocate forming a group by accepting, within limits, the first suitable seven or eight candidates screened and deemed to be good group therapy candidates. We suggest having an equal number of men and women and a wide range of ages, interactional styles, and expected levels of activity and engagement. The therapist’s paramount task is to create a group that coheres. There is no question that composition radically affects a group’s character. Yet, given the current state of our knowledge and clinical practice, there is no justification for spending a great deal of time and energy on delicately casting and balancing a group. We believe that therapists do better to invest their time and energy in careful selection of clients for group therapy in general, as well as in pretherapy preparation, which we will discuss in the next chapter. If the group coheres and the leaders appreciate the therapeutic factors, and are flexible and thoughtful in their leadership role, they can make therapeutic use of virtually any conditions (other than lack of motivation) that arise in the group. Footnotes i The dropout categories have substantial overlap. Many of the clients who dropped out because of problems of intimacy began to occupy a deviant role because of the manifestations of their intimacy problems. ii Adding a measure of attachment to the initial evaluation can be very helpful. Although the gold standard for the measurement of attachment is an intensive, structured interview, such as the Adult Attachment Interview, simpler and quicker self-reports add value and can be accessed online at “The Self-Assessment Kiosk,” Sinai Health System and University of Toronto, at Survey Gizmo, www.surveygizmo.com/s3/2998552/The-Self-Assessment-Kiosk. The Relationship Style Q, a modified form of the ECR—Experiences in Close Relationships Scale—is a well-validated attachment self-report, and the Kiosk scores it automatically and quickly, providing both quantitative and qualitative client feedback. iii Psychological-mindedness is the ability to identify intrapsychic factors and relate them to one’s difficulties. The Quality of Object Relations (QOR) Scale evaluates clients’ characteristic manner of relating along a continuum ranging from mature to primitive. Chapters 9 Creating the Group ONCE THE CLIENTS FOR A THERAPY GROUP ARE SELECTED, group therapists must turn their attention to launching the group.1 First, therapists must secure an appropriate meeting place and make a number of practical decisions about the structure of their group: its size and life span, the admission of new members, the frequency of meetings, and the duration of each session. Considerations for leading psychotherapy groups online will be discussed in Chapter 14. In addition to the therapy group itself we must also consider a second “group”—the group of colleagues who will refer clients; the administrators who support the structure required for success; and the third-party payer, insurer, or managed care organization that may be paying for the treatment.2 Good collaboration with this second group is essential to the success of the therapy group. Groups that meet under the auspices of an organization (for example, a community agency or hospital clinic) may be affected by that organization’s culture, level of stability, and attitudes toward psychotherapy.3 In private practice, many practitioners publicize their clinical work and their models of therapy through the use of engaging websites and social media. Although marketing may feel commercial at first, it is merely the contemporary version of professional networking. A professional presence on Facebook, Twitter, LinkedIn, YouTube, and Instagram can inform prospective referral sources and clients of your group therapy offerings. Workshops for group therapists on using social media to help grow their practices have become popular.4 Publicizing one’s work is more than self-promotion. Clinicians have a responsibility to educate the public, destigmatize group therapy, and build strong clinical practice organizations with well-trained clinicians who are properly credentialed, ideally as Certified Group Psychotherapists (CGPs).5 They must urge third-party payers to attend to the robust empirical research supporting group therapy’s effectiveness. The recognition of group psychotherapy as a designated professional specialty by the American Psychological Association will elevate the status of group therapy and underscore the importance of proper group therapy training and continued professional development.6 Many colleagues and administrators unfamiliar with group therapy tend to devalue it until they are educated about its effectiveness and its equivalence to individual therapy in outcome. Our clinical and administrative colleagues also need to understand that group therapy is a complex treatment to deliver and requires therapist expertise. Many college counseling centers, for example, have a group therapy coordinator who is responsible for informing referral sources and prospective clients about the efficacy and mechanics of therapy groups. It is constructive to have a group therapy champion in institutional settings.7 SETTING AND STRUCTURE Group meetings may be held in any room that affords privacy and freedom from distractions. In institutional settings, the therapist must negotiate with the administration to establish an inviolate time and space for the therapy group. The first step of a meeting is to form a circle so that members can all see one another. To be avoided are seating arrangements that block members’ views of one another, such as long, rectangular tables, or sofas that seat three or four people. If members are absent, most therapists prefer to remove the empty chairs and form a tighter circle to foster cohesion. If the group session is to be videotaped or observed through a one-way mirror by trainees, the group members’ permission must be obtained in advance and ample opportunity provided for discussion of the procedure. Written consent is essential if any audiovisual recording is planned, even if it is to be used only for supervision purposes. A group that is observed usually seems to forget about the observation after a few sessions, unless there are unresolved group issues about trust, power, or safety. If only one or two students are regular observers, we suggest seating them in the room but outside of the group circle. This avoids the intrusion of the mirror and allows the students to sample more of the group affect, which inexplicably is often filtered out by the mirror. Observers should be cautioned to remain silent and to resist any attempts by group members to engage them in the discussion. (See Chapter 16 for further discussion about group observation.) Open and Closed Groups The leader determines if the group is to be open or closed. A closed group, once begun, shuts its gates; accepts no new members, except perhaps within the first two or three sessions; and meets for a predetermined length of time. An open group, by contrast, maintains a consistent size by replacing members as they leave the group. Groups may have a predetermined life span—for example, groups in a college counseling service may plan to meet only through the academic year. In other settings, many open groups continue indefinitely, even though every couple of years there may be a complete turnover of group membership—at times including leadership changes. We know of therapy groups in psychotherapy training centers that have endured for twenty or thirty years and are bequeathed every year or two by a graduating therapist to an incoming student therapist. Open groups tolerate changes in membership better if there is some consistency in leadership. One way to achieve this in the training setting is for the group to have co-therapists, and when the senior co-therapist leaves, the remaining therapist continues as the senior group leader and a new co-therapist joins.8 Such continuity maintains the culture and cohesion of the group. Most closed groups are briefer therapy groups that meet weekly for eight months or less. A longer closed group may have difficulty maintaining membership stability. Invariably, members drop out, move away, or face some unexpected scheduling incompatibility. Groups do not function well if they become too small, and new members must be added lest the group perish from attrition. For that reason, we advise starting closed groups with nine or ten members so that a core of six or seven is likely to remain in the group until its conclusion. A long-term closed-group format is feasible in a setting that assures considerable stability, such as a prison, a military base, and occasionally an outpatient group in which all members are concurrently in individual psychotherapy with the group leader (see Chapter 13). Some therapists lead a closed group for six months, at which time members evaluate their progress and decide whether to commit themselves to another six months.9 Some intensive partial hospitalization programs begin with an intensive phase of closed group therapy, which is followed by an extended, open group therapy aftercare maintenance phase. The closed phase emphasizes common concerns and acquisition of fundamental skills. The open phase aims to reduce relapse, reinforces the gains made during the intensive phase, and helps clients apply their gains more broadly in their own social environments. Some clients may attend monthly booster group sessions indefinitely. This model has worked well in the treatment of substance abuse, trauma, and geriatric depression.10 Size of the Group What is the optimal size for a successful therapy group? Our own experience and a consensus of the clinical literature suggest that the ideal size of a cohesive interactional therapy group is seven or eight members, with an acceptable range of five to nine members.11 Louis Ormont reported good success with a group size as large as twelve to fourteen members, a model employed by some practitioners of the modern group analytic model.12 And the smallest size of an effective group? When a group is reduced to four or fewer members, it often ceases to operate as a group; member interaction diminishes, and therapists can find themselves engaged in individual therapy within the group. A small group is manageable over a short period due to vacations and absences, but in the long run, members disengage; many of the advantages of a group, especially the opportunity to interact and analyze one’s interactions with a large variety of individuals, are compromised. Small groups become passive, suffer from stunted development, and frequently develop a negative group image.13 Obviously, the group therapist must replace members quickly, but appropriately. If new members are unavailable, therapists do better to meld two small groups rather than to continue limping along with insufficient membership in both. Acknowledging that a group has too few members to flourish emancipates the clients and therapist for new therapeutic opportunities. The upper limit of therapy group members is determined by sheer economic principles. As the group increases in size, less and less time is available for the working through of any individual’s problems. If members do not feel they are at the center of the group, cohesion will suffer. Subgrouping may emerge as clients try to find some way to reduce their sense of isolation in the group.14 Since it is likely that one, or possibly two, clients will drop out of the group in the course of the initial meetings, many therapists start a new group with eight to ten members. Starting with a group size much larger than ten in anticipation of dropouts may become a self-fulfilling prophecy. Some members will quit because the group is simply too large for them to participate productively. Larger groups of twelve to sixteen members may meet productively in day hospital settings, because each member is likely to have many other therapeutic opportunities over the course of each week. Alcoholics Anonymous and other twelve-step groups that do not focus on interpersonal interaction (these groups in fact discourage interpersonal feedback and label it as crosstalk; see Chapter 13) may range from twenty to eighty participants. Psychoeducational groups for conditions such as generalized anxiety may meet effectively with twenty to thirty participants; these groups actively discourage individual disclosure and interaction, relying instead on imparting information about anxiety and stress reduction.15 Similar findings have been reported in the treatment of panic disorder and agoraphobia as well as a range of other conditions.16 The large-group format has also been used with cancer patients, often accompanied by training in stress reduction and self-management of illness symptoms or medical treatment side effects. These groups may contain forty to eighty participants meeting weekly for two hours over a course of six weeks.17 If we think of the health-care system as a pyramid, large groups of this type are part of the broad base of accessible, inexpensive treatments at the system’s entry level. For many, this provision of knowledge and skills is sufficient. Clients who require more assistance may move up the pyramid to more focused or intensive interventions.18 A range of therapeutic factors may operate in these groups. Large homogeneous groups accept, humanize, normalize, destigmatize, activate feelings of universality, and offer skills and knowledge that enhance self-efficacy. AA groups offer inspiration, guidance, and practical tools for dealing with the challenges of a sober life. Altruism also plays a role—helping others reinforces self-esteem and deepens a personal sense of mastery. Duration and Frequency of Meetings For many years, the length of a psychotherapy session has been static: the fifty-minute individual hour and the eighty- to ninety-minute group therapy session were part of the entrenched wisdom of the field. Most group therapists agree that, even in well-established groups, at least sixty minutes is required for the warm-up interval and for the unfolding and working through of the major themes of the session. There is also some consensus among therapists that after about two hours, the session reaches a point of diminishing returns: the group becomes weary, repetitious, and inefficient. Moreover, therapists appear to function best in segments of eighty to ninety minutes; with longer sessions therapists often become fatigued and less effective. Although the frequency of meetings varies from one to five times a week, the overwhelming majority of groups meet once weekly. It is often logistically difficult to schedule multiple weekly outpatient group meetings, and few therapists have led an outpatient group that meets more than once a week. But, were it possible, we would choose to meet with groups twice weekly: such groups are more intense, the members continue to work through issues raised in the previous session, and the entire process takes on the character of a continuous meeting. Some therapists meet twice weekly for two or three weeks at the start of a time-limited group to launch the group and turbocharge its intensity before moving to a once-weekly model.19 Weekly sessions promote a greater therapeutic connection, whereas groups meeting less frequently have difficulty maintaining an interactional focus and instead tend to focus on life events and crisis resolution. Less frequent meetings are less efficient and result in lengthened treatment.20 Set a meeting time that facilitates group members’ attendance. Group therapists in private practice recognize the demands of consistently working some evenings as a fact of life. In efforts to achieve “time-efficient therapy,” group leaders have experimented with many aspects of the frame of therapy, but none more than the duration of the meeting.21 Back in the heyday of encounter groups in the 1960s and 1970s, therapists held weekly meetings that lasted four, six, even eight hours—a protocol that now seems both worrisome and wondrous. Some group therapists referred their entire group for a weekend with another therapist or, more commonly, conducted a marathon meeting with their own group sometime during the course of therapy. The objective was to accelerate therapy by exhausting group members and mobilizing group pressure to wear down member resistance and promote deeper and deeper disclosure. The time-extended format was later adapted by such commercial enterprises as EST (Erhard Seminars Training) or Lifespring. Today, these large group awareness training programs have virtually disappeared.22 The therapists who still regularly or periodically hold time-extended group meetings represent a small minority of practitioners. There have been occasional recent reports of intensive, and effective, retreat weekends for various conditions, such as substance abuse, panic disorder, PTSD, and bulimia.23 These approaches consist of a comprehensive program that includes group therapy and psychoeducation but not the intensive confrontation and fatigue characteristic of the marathon approach. Some therapists augment weekly group therapy for clients with cancer with an intensive weekend retreat for skill building, reflection, and meditation. Mindfulness group therapies often supplement weekly sessions with one or two full-day weekend meetings. But the purpose is intensive meditational practice rather than wearing down clients’ ego defenses.24 We make reference to the marathon movement not because it has much current usage, or to pay homage to it as a chapter in the history of psychotherapy, but because of what it reveals about how therapists make clinical practice decisions. Over the past several decades, our field has been taken by storm through a series of ideological and stylistic fads. Reliance on the fundamentals of our work and on well-constructed systematic research is the best bulwark against being swept along and zealously embracing and then quickly discarding the fashion of the day. Highly extravagant claims about the effectiveness of marathon group therapy were widely publicized at the time but were based entirely on anecdotal reports of various participants or on questionnaires distributed shortly after the end of a meeting—an exceedingly unreliable approach to evaluation. In fact, any outcome study based solely on interviews, testimonials, or client self-administered questionnaires obtained immediately at the end of the group is of questionable value. At no other time is the client more loyal, more grateful, and less objective about a group than at termination, when there is a powerful tendency to recall and to express only positive, tender feelings. Experiencing and expressing negative feelings about the group at this point would be unlikely for at least two reasons: (1) there is strong group pressure at termination to participate in positive testimonials—few group participants, as Solomon Asch has shown, can maintain their objectivity in the face of apparent group unanimity;25 and (2) members reject critical feelings toward the group at this time to avoid a state of cognitive dissonance. In other words, once an individual invests considerable emotion and time into a group and develops strong positive feelings toward other members, it becomes difficult to question the value or activities of the group. Is it possible, as is sometimes claimed, that a time-extended meeting accelerates the maturation of a therapy group, and that it increases openness, intimacy, and cohesiveness, thus facilitating insight and therapeutic breakthroughs? My (IY) colleagues and I studied this question and found that marathon sessions at the start of a course of group therapy did not favorably influence the communication patterns in subsequent meetings.26 In fact, there was a trend in the opposite direction: after the six-hour meetings, the groups appeared to engage in less here-and-now interaction. The influence of the six-hour meeting on cohesiveness was quite interesting. In the three groups that held a six-hour initial meeting, there was a trend toward decreased cohesiveness in subsequent meetings. In the three groups that held a six-hour eleventh meeting, however, there was a significant increase in cohesiveness in subsequent meetings. Thus, timing is a consideration: it is entirely possible that, at a particular juncture in the course of a group, a time-extended session may help increase member involvement in the group. These results showed that cohesiveness can be accelerated but not brought into being by time-extended meetings. The marathon group phenomenon makes us mindful of the issue of transfer of learning. There is no question that the time-extended group can evoke powerful affect and can encourage members to experiment with new behavior. But does a change in one’s behavior in the group invariably beget a change in one’s outside life? Clinicians have long known that change in the therapy session is not tantamount to therapeutic success. Change, if it is to be consolidated, must be carried over into important outside interpersonal relationships and endeavors and tested again and again in these natural settings. Of course, therapists wish to accelerate the process of change, but the evidence suggests that it is the duration, consistency, and frequency of treatment that is central to therapy’s effectiveness. The transfer of learning is laborious and demands a certain irreducible amount of time—even more so for individuals who have had chronic mood, characterological, and interpersonal difficulties.27 Consider, for example, a male client who, because of his early experience with an authoritarian, distant, and harsh father, tends to see other males, especially those in a position of authority, as having similar qualities. In the group he may have an entirely different emotional experience with a male therapist and perhaps with some of the male members. What has he learned? Well, for one thing he has learned that not all men are frightening bastards—at least there are one or two who are not. Of what lasting value is this experience to him? Probably very little unless he can generalize the experience to future situations. He must learn how to differentiate among people so as not to perceive all men in a predetermined manner. Once he is able to make the necessary discriminations, he must learn how to go about forming relationships on an egalitarian, distortion-free basis. For the individual whose interpersonal relationships have been impoverished and maladaptive, these are formidable and lengthy tasks that often require the continual testing and reinforcement available in the long-term therapeutic relationship. BRIEF GROUP THERAPY Brief group therapy has become an important and widely used therapy format. Third-party insurers and therapists as well strive relentlessly for briefer, less expensive, and more efficient forms of therapy.i A survey of managed care administrators responsible for the health care of over seventy-three million participants noted that they were interested in the use of more groups but favored brief, problem-homogeneous, structured groups.28 Other factors also favor brief therapy. For example, many geographic locations have high service demands and low availability of mental health professionals; here, brevity translates into greater access to services. College counseling centers use a wide range of brief, tailored group therapies to meet the growing mental health needs of their student clients.29 Brief group therapy can also play a key role in a stepped care model: as a starting point, or setting the stage for further therapy, or sufficient in itself. How long is “brief”? Some clinicians define brief as sixteen to twenty-five sessions, and others as fifty or sixty meetings.30 Inpatient groups, with rapid turnover, may be thought of as having a life span of a single session. The research on cohesion suggests twelve sessions as the shortest duration for an effective brief therapy group.31 Twelve sessions also appears to be the minimum “dose” required to ensure that at least 50 percent of clients in therapy will improve.32 Alternately, we can offer a functional rather than a temporal definition: A brief group is the shortest group life span that can achieve some specified goal—hence the felicitous term “time-efficient group therapy.”33 A group dealing with an acute life crisis, such as a job loss, might last four to eight sessions, whereas a group addressing major relationship loss, such as divorce or bereavement, might require twenty or more. A group for dealing with a specific symptom complex, such as eating disorders or sexual abuse victims, might last eighteen to twenty-four sessions. A “brief” group with the goal of changing enduring characterological problems might last twenty or more sessions.34 There are promising approaches that are even briefer, often eight sessions, and utilize intensive preparation to identify a specific interpersonal focus for each group member to work on in the group.35 Explorations into the “dose-effect” of individual psychotherapy shed some light on the question of duration of therapy as it relates to patterns of improvement. This research looks at patterns of improvement over time for clients with a range of clinical concerns.36 Although no comparable dose-effect research in group therapy has been reported, it seems reasonable to assume that there are similar patterns of response to group therapy. Researchers note that clients who normally cope well but who are facing a crisis generally require a small number of therapy hours to achieve significant improvement. Often eight sessions or fewer are sufficient to return many clients to their precrisis level. The vast majority of clients with more chronic difficulties require about fifty to sixty sessions to improve, and those with significant personality disturbances require even more. The greater the impairment in trust and the earlier in one’s development the individual has suffered loss or trauma, the greater the likelihood that brief therapy will be insufficient. Many clients with chronic depression who show initial improvement require a longer continuation phase of therapy to reduce the risk of relapse. Failure of prior brief therapies is also often a sign of the need for a longer therapy.37 The reality that many of our clients need longer treatments is often neglected and clients are often undertreated. The actual measurement of client progress coupled with regular objective feedback about the client’s experience of therapy can aid in determining how much therapy is sufficient (see Chapter 13).38 Whatever the precise length of therapy, all brief psychotherapy groups share many common features. They all strive for efficiency; they contract for a discrete set of goals and attempt to stay focused on goal attainment; they tend to stay in the present (with either a here-and-now focus or a “there-and-now” recent-problem-oriented focus); they draw attention to the temporal restrictions to accelerate client engagement; they emphasize the transfer of learning from the group to the real world; their composition is often homogeneous for some problem, symptomatic syndrome, or life experience; and they focus more on interpersonal than on intrapersonal concerns.39 Pregroup preparation, clarity about goals, attention to client culture and identity, and a clear therapeutic focus are of particular importance in brief group therapy.40 For some clients a brief course of group therapy may be the entire treatment, whereas for others it may be considered an installment of treatment—an opportunity to do a piece of important work, which may or may not require other installments in the future.41 It is important that we recognize both the power and the limits of brief group therapy. Keep in mind that if the brief group therapy has been effective, it is likely that client gains will continue to consolidate after active therapy ends.42 When leading a brief therapy group, a group therapist is wise to heed these general principles: • The brief group is not a truncated long-term group.43 Group leaders must have a different mental set: they must clarify goals, focus the group, manage time, and be active and efficient. Since group members tend to deny their group’s temporal limits, leaders of brief groups must act as group timekeeper, periodically reminding the group how much time has passed and how much remains. The leader should regularly make comments such as: “This is our twelfth meeting. We’re two-thirds done, but we still have six more sessions. It might be wise to spend a few minutes today reviewing what we’ve done, what goals remain, and how we should invest our remaining time. Let’s make sure we leave as little unsaid and undone as possible.” • Leaders must attend to the transfer of learning by encouraging clients to apply what they have learned in the group to their situations outside the group. They must emphasize that treatment is intended to set change in motion, but not necessarily to complete the process within the confines of the scheduled treatment. • Leaders should attempt to turn the disadvantages of time limitations into an advantage. Since the time-limited therapy contributions of Carl Rogers, we have known that imposed time limits may increase efficiency and energize the therapy.44 Also, the fixed, imminent ending may be used to heighten awareness of the existential dimensions of life: time is not eternal; the immediate encounter matters; the ultimate responsibility rests within, not without: there will be no magic solution to problems.45 This approach counters the posture of resistance common to clients of “What can we do in so short a time?” and is useful in even the briefest of groups. • Keep in mind that the official name of the group does not determine the work of therapy. Just because the group is made up of recently divorced individuals or survivors of sexual abuse does not mean that the focus of the group is “divorce” or “sexual abuse.” It is far more effective for the group’s focus to be interactional, directed toward those aspects of divorce or abuse that have ramifications in the here-and-now of the group. For example, clients who have been abused can work on their shame, their rage, their reluctance to ask for help, their distrust of authority (often focused upon the leaders), and their difficulty in establishing intimate relationships. Groups of recently divorced members will work most profitably not by a prolonged historical focus on what went wrong in their marriages but by examining each member’s problematic interpersonal issues as they manifest in the here-and-now of the group. Members must be helped to recognize and change these patterns so that they do not impair future relationships. This may feel like an unnatural focus for clients seeking support and comfort and therefore should be anticipated and addressed in the pregroup preparation sessions. Processing within the here-and-now (“hot processing”) is more powerful than processing external relationships outside of the group (“cold processing”).46 • Effective group therapists should be flexible and use all means available to increase efficacy. Techniques from cognitive or behavioral therapy may be incorporated into the interactional group to alleviate symptomatic distress. For example, the leader of a group for binge eating may recommend that members explore the relationship between their moods and their eating in a written journal, or log their food consumption, or meditate to reduce emotional distress. But by no means is this the sole approach available: brief group work that focuses on the interpersonal concerns that reside beneath the food-related symptoms is as effective as brief group work that targets the disordered eating directly.47 In other words, therapists can think of symptoms as issuing from disturbances in interpersonal functioning and alleviate the symptom by repairing the interpersonal disturbances. • Time is limited, but leaders must not make the mistake of trying to save time by abbreviating the pregroup individual session. On the contrary, leaders must exercise particular care in preparation and selection.48 The most important single error made by busy clinics is to screen new clients by phone and immediately introduce them into a group without an individual screening or preparatory session. Such an approach undermines the client’s alliance with the group leader and hampers the development of group cohesion. Brief groups are less forgiving of errors than long-term groups. When the life of the group is only, say, twelve sessions, and two or three of those sessions are consumed by attending to an unsuitable member who then drops out (or must be asked to leave), the cost is very high: the development of the group is obstructed, levels of trust and cohesion are slower to develop, and a significant proportion of the group’s precious time and effectiveness is sacrificed. • Use the pregroup individual meeting not only for standard group preparation but also to help clients reframe their problems and sharpen their goals so as to make them suitable for brief therapy.49 Some group therapists will use the first group meeting to ask each client to present his or her interpersonal issues and treatment goals as a way of jump-starting the group.50 Some clinicians have sought creative ways to bridge the gap between brief and longer-term treatment. One approach is to follow the brief group with booster group sessions scheduled at greater intervals, perhaps monthly, for another six months.51 Another approach offers clients a brief group but provides them with the option of signing on for another series of meetings. One program for clients with chronic illness consists of a series of twelve-week segments with a two-week break between segments.52 Members may enter a segment at any time until the sixth week, at which time the group becomes a closed group. A client may attend one segment and then choose at some later point to enroll for another segment. The program has the advantage of keeping all clients, even the long-term members, goal-focused. Are brief groups effective? Outcome research on brief group therapy has increased substantially, and for many clients, the answer is a clear yes. We summarize only a few notable findings here and encourage readers to examine the comprehensive summary of this literature published by the American Group Psychotherapy Association and other comprehensive reviews.53 An analysis of forty-eight reports of brief therapy groups (both cognitive-behavioral and dynamic/interpersonal) for the treatment of depression demonstrated that groups that met, on average, for twelve sessions produced significant clinical improvement: group members were almost three times more likely to improve than clients waiting for treatment.54 Furthermore, therapy groups add substantially to the effect of pharmacotherapy in the treatment of depression.55 Both expressive-interpretive groups and supportive groups for clients with loss and grief have been proven effective.56 Meta-analyses and reviews also confirm that brief group therapy is effective for clients with binge eating disorders or with panic disorder.57 Clients with borderline personality disorder reported improvement in mood and behavior at the end of twenty-five sessions.58 Brief group therapy is also effective in the psychological treatment of the medically ill. It improves coping and stress management, reduces mood and anxiety symptoms, and improves self-care.59 How do brief and longer-term group therapy compare? A well conducted comparative trial of brief versus longer-term group analytic therapy (twenty sessions vs. eighty sessions) showed remarkable and equivalent effectiveness across a range of clinical difficulties. The briefer treatment also had much lower dropout rates. The researchers noted that the brief group therapy was more challenging to deliver well and required much higher levels of therapist activity. Not surprisingly, however, clients with personality disorders benefited more from the longer-term treatment.60 In sum, research demonstrates the effectiveness of brief group therapy.61 We can lead brief groups with confidence; we know there is much we can offer clients in the brief format. But clients with evidence of chronic psychological or characterological difficulties and a history of failed brief therapies require a longer-term group. Don’t be swept away by the powerful contemporary push for efficiency at the expense of client need. One of the architects of the NIMH Collaborative Treatment of Depression Study, one of the largest psychotherapy trials ever conducted, raised a caution that our field has likely oversold the power of brief psychotherapy.62 PREGROUP MEETINGS AND PREPARATION FOR GROUP THERAPY There is great variation in clinical practice regarding individual sessions with clients prior to group therapy. Some therapists, after seeing prospective clients once or twice in selection interviews, do not meet with them individually again, whereas others continue individual sessions until the client starts in the group. If several weeks are required to accumulate sufficient members, the therapist is well advised to continue to meet with each member periodically to prevent significant attrition. At the very least we recommend a follow-up meeting closer to the start of the group, which is also an ideal time for a preparation session. Even in settings with plenty of appropriate group therapy referrals, it is important to maintain client momentum and interest. One way to do this is to set a firm start date for the group and then focus energetically on recruitment and assessment. A group leader may need to invest twenty to twenty-five hours in selection and preparation to assemble one group. It is always time well spent. It is our clinical impression that the more often clients are seen by their group leader before entering the group, the less likely they are to terminate prematurely from the group. Often the first step in the development of bonds among group members is their mutual identification with the therapist. Keep in mind that the purpose of the individual pregroup sessions is to build a therapeutic alliance in which client and therapist agree about the goals and tasks of group therapy as well as the nature of the relationship they hope to develop. This, in turn, sets the stage for the development of group cohesion. One other overriding task must be accomplished in the pregroup interview or interviews: the preparation of the client for group therapy. If we had to choose the one area where research has the greatest relevance for practice, this would be it: There is highly persuasive evidence that pregroup preparation plays a very positive—even an essential—role in the course of group therapy. Group leaders must achieve several specific goals in the preparatory procedure: • Clarify misconceptions and unrealistic fears about group therapy • Anticipate and diminish the emergence of problems in the group’s development • Provide clients with a cognitive structure that facilitates effective group participation • Generate realistic and positive expectations about the group therapy • Challenge clients’ stigmatizing myths and negative assumptions about group therapy Misconceptions About Group Therapy Certain misconceptions and fears about group therapy are so common that if the client does not mention them, the therapist should point them out as potential problems. Despite powerful research evidence on the efficacy of group therapy, many people still believe that group therapy is second-rate. Clients may think of group therapy as cheap therapy—an alternative for people who cannot afford individual therapy or a way for insurers to increase profits. Others regard it as diluted therapy because each member has only twelve to fifteen minutes of the therapist’s time each week. Still others believe that the raison d’être of group therapy is to accommodate more clients with fewer therapists. Such misunderstandings continue to pose a challenge for many clients, even in the current era of greater public attention regarding mental health. Let us illustrate by examining some representative surveys of public beliefs about group therapy. A number of surveys of individuals seeking mental health care, including college students and community members, identify common concerns and misconceptions:63 • Group therapy is wild and unpredictable and involves a loss of personal control—for example, groups may coerce members into uncomfortable self-disclosure. • Group therapy is not as effective as individual therapy because effectiveness is proportional to the attention received from the therapist. • Group therapy generates greater risk of feelings of shame and rejection. • Being in a group with many individuals with significant emotional disturbance is in itself detrimental and can worsen the mental health of vulnerable individuals. Individual therapy is widely preferred to group therapy, particularly by men. Culture plays a role as well. Clients from non-Western and collectivist traditions may be apprehensive about public displays of emotion or of personal need. Fear of shame may be crippling.64 A British National Health Service study of sixty-nine moderately distressed clients seeking therapy reported that more than 50 percent declared that they would not enter group therapy even if no other treatment were available. Clients feared ridicule and shame, the lack of confidentiality, and being made worse through some form of contagion. What are some of the sources of this strong antigroup bias? For many of our clients, the natural groups that have been part of their lives have usually been “part of the problem,” not “part of the solution.” The client’s initial reaction to the idea of participating in group therapy may be recollections of bullying and marginalization. Hence, groups in general are distrusted, and the individual therapy setting is considered a more protected, safe, and familiar zone. This is particularly the case for those with no prior experience in therapy.65 In general, the media and fictional portrayals of group therapy are vastly inaccurate, often portraying therapy groups in a mocking, ridiculing fashion.ii Reality television shows may also play a role. They speak to our unconscious fears of being exposed and extruded from our group because we are found to be defective, deficient, or are deemed to be the “weakest link.”66 Whatever their sources, such misconceptions and apprehensions must be countered; otherwise these strong negative expectations may make successful group therapy outcome unlikely. Nor are these unfavorable expectations limited to the general public or to clients. A survey of psychiatric residents found similar negative attitudes toward group therapy.67 Lack of exposure in psychiatry training programs is part of the problem, but the strength of resistance to remedying these training shortfalls suggests that antigroup attitudes may be deeply rooted and even unconscious. Thus, it should not surprise us to find such attitudes within institutional and administrative leadership. The biological-psychological split in current psychiatry fuels these kinds of prejudices as the field polarizes between a focus on the brain and a focus on the mind, as though these were disconnected in the experience of our clients.68 Furthermore, the challenge of learning to lead groups is significant, and human nature often leads us to devalue that which makes us anxious.69 In addition to evaluative misconceptions, clients usually harbor procedural misconceptions and unrealistic interpersonal fears. Many of these are evident in the following dream that a client reported at her second pregroup individual session shortly before she was to attend her first group meeting: > I dreamed that each member of the group was required to bring cookies to the meeting. I went with my mother to buy the cookies that I was to take to the meeting. We had great difficulty deciding which cookies would be appropriate. In the meantime, I was aware that I was going to be very late to the meeting, and I was becoming more and more anxious about getting there on time. We finally selected the cookies and proceeded to go to the group. I asked directions to the room and was told that it was meeting in room 129A. I wandered up and down a long hall in which the rooms were not numbered consecutively and in which I couldn’t find a room with an “A.” I finally discovered that 129A was located behind another room and entered. While looking for the room, I had encountered many people from my past, schoolmates and folks I had known for years. The group was large: about forty or fifty people were milling about. I saw members of my family—most specifically, two of my brothers. Each member had to stand up and talk about their problems. The whole dream was very anxiety-provoking—especially being late and the huge number of people in the group. << Several themes are abundantly clear in this dream. The client anticipated the first group meeting with considerable dread. Her concern about being late reflected a fear of being excluded or rejected by the group. Furthermore, since she was starting in a group that had already been meeting for several weeks, she feared that the others had progressed too far, that she would be left behind and could never catch up. (She could not find a room with an “A” marked on it.) She dreamed that the group would number forty or fifty. Concerns about the size of the group are common; members fear that their unique individuality will be lost as they become one of the mass. Moreover, clients erroneously apply the model of the economic distribution of goods to the group therapeutic experience, assuming that the size of the crowd is inversely proportional to the goods received by each individual. The dream image of each member confessing problems to the group audience reflects one of the most common and pervasive fears of individuals entering a therapy group: the horror of having to reveal oneself and confess shameful transgressions and fantasies to a large alien audience. What’s more, members imagine a critical, scornful, ridiculing, or humiliating response from the other members. The experience is fantasized as an apocalyptic trial before a stern tribunal. The dream also suggests that pregroup anxiety stemmed from anxiety linked to early group experiences, including those of school, family, and play groups. It is as if her entire social network—all the significant people and groups she had encountered in her life—would be present in this group. (In a metaphorical sense, this is true: to the degree that she had been shaped by other groups and other individuals she would carry them into the group with her, since they were part of her character structure; furthermore, she would, transferentially, re-create in the therapy group her early significant relationships.) It is clear from the reference to room 129 (an early schoolroom in her life) that the client was associating her impending group experience with a time in her life when few things were more crucial than the acceptance and approval of a peer group. Furthermore, she anticipated that the therapist would be like her early teachers: an aloof, unloving evaluator. Closely related to the dread of forced confession is the concern about confidentiality. The client anticipated that there would be no group boundaries, that every intimacy she disclosed would be known by every significant person in her life. Other common concerns of individuals entering group therapy, not evident in this dream, include a fear of mental contagion, of being made sicker through association with ill co-members. Often, but not exclusively, this is a preoccupation of clients with fragile ego boundaries who lack a solid, stable sense of self. The anxiety about regression in an unstructured group and being helpless to resist the pull to merge and mesh with others can be overwhelming. In part, this concern is also a reflection of the self-contempt of individuals who project their feelings of worthlessness onto others. Such dynamics underlie the common query, “How can the blind lead the blind?” Convinced that they themselves have nothing of value to offer, some clients find it inconceivable that they might profit from others like themselves. Others fear their own hostility. They think that if they ever unleash their rage, it will engulf them as well as others. The notion of a group where anger is freely expressed is terrifying. They think silently, “If others only knew what I really thought about them.” All of these unrealistic expectations—which, if left unchecked, lead to a rejection or a blighting of group therapy—can be allayed by adequate preparation of the client. There is compelling research evidence that addressing clients’ negative treatment expectations contributes significantly to improved treatment outcomes.70 It is also notable that many neophyte group therapists report similar dreams on the cusp of starting their first group. Anticipating Common Group Problems Before outlining a preparation procedure, we will consider four problems commonly encountered early in the course of groups that may be ameliorated by pregroup preparation. • One important source of confusion and discouragement for clients early in therapy is perceived goal incompatibility. They may be unable to discern the congruence between group goals (such as group integrity, construction of an atmosphere of trust, and an interactional focus) and their individual goals (relief of suffering). What bearing, members may wonder, does a discussion of their personal reactions to other members have on their own symptoms of anxiety, depression, phobias, compulsions, or insomnia? • A high turnover in the early stages of a group is, as we have discussed, a major impediment to the development of an effective group. From the very first contact with a client, the therapist should discourage irregular attendance and premature termination. We often employ the analogy of group therapy being a team sport: if you are part of the team, you have to show up. The issue is more pressing than in individual therapy, where absences and tardiness can be profitably investigated and worked through. In the initial stages of the group, irregular attendance results in a discouraged and disconnected group. It is good to discuss this issue preemptively, as it is enormously frustrating to address it in the group when the offending client is yet again absent. • Group therapy, unlike individual therapy, often does not offer immediate comfort. Clients may be frustrated by not getting enough “airtime” in the first few meetings; they may feel deprived of their specialness, or they may feel anxious about the task of direct interpersonal interaction. The therapist should anticipate and address this frustration and anxiety in the preparatory procedure. This is a particular challenge for clients who have found individual therapy to be narcissistically gratifying. It is also a challenge for clients familiar with twelve-step groups, in which interpersonal feedback or “crosstalk” are often actively discouraged. • Subgrouping and extragroup socializing, which has been referred to as the Achilles’ heel of group therapy, may be encountered at any stage of the group. This complex problem will be considered in detail in Chapter 11. Here it is sufficient to point out that the therapist may begin to shape the group norms regarding these group phenomena in the very first contact with the clients. The Process of Preparation There are many approaches to preparing clients for group therapy. The simplest and most practical in the harried world of everyday clinical practice is to offer the necessary information in the pregroup interview. We suggest setting aside sufficient time for this discussion and meeting with clients at least twice before introducing them into the group. But even if we see a client only once, we reserve at least half the time to address each of the foregoing misconceptions and initial problems of group therapy. We share our predictions with the client about the early problems that may arise in the group and the probable emergence of familiar patterns. In addition, we present a conceptual framework and clear guidelines for effective group behavior. Each of these meetings must be individualized according to the client’s presenting questions, concerns, and level of sophistication regarding the therapy process. Two situations require particular attention from the therapist: the therapy neophyte and the client with ethnocultural, diversity, and identity concerns. The client who has never been in any form of therapy may find group therapy particularly challenging and may require additional pregroup individual preparation. Clients from non-Western cultures may be particularly threatened by the prospect of intimate personal exposure in the group. The pregroup preparation sessions provide the therapist the opportunity to explore the impact of the client’s culture on his or her attitudes and beliefs and also to demonstrate the therapist’s genuine willingness to enter the client’s world.71 Similar attention is required for clients with LGBTQ identity and diversity concerns. Clients who do not identify as cisgendered will need reassurance that the group will be an open and welcoming space for them.72 We routinely approach the preparation session with the following objectives: • We offer a clear conceptual framework of the interpersonal basis of pathology. Keep in mind that the contemporary emphasis on the biological base of psychological disorders is disheartening to most clients. It increases stigma and helplessness. Clients’ preference for therapy stems from their wish to feel active and effective in their own care and the psychosocial therapies offer that.73 • Describe how the therapy group addresses and corrects interpersonal problems. • Offer guidelines about how best to participate in the group. • Anticipate the frustrations and disappointments of group therapy, especially of the early meetings. • Offer guidelines about duration of therapy. Make a contract about attendance in group. • Instill faith in group therapy. Welcome your client’s query—“Will this help me?” Your realistic optimism (harder, of course, to muster for neophyte therapists) can offset your clients’ pessimism. The client is often seeking reassurance to counter their discouragement. • Set ground rules about confidentiality, including communication with other providers for those clients in concurrent treatments. • Address subgrouping and extragroup socializing. Now, to flesh out each of these points. First, we present clients whom we believe will benefit from group therapy with a brief explanation of the interpersonal theory of psychiatry, beginning with the statement that although each person manifests his or her problems differently, they often have in common the basic difficulty of establishing, maintaining, or navigating close and gratifying relationships with others. We remind them of the many times in their lives that they have undoubtedly wished to be really honest about their positive and negative feelings with someone and get reciprocally honest feedback. The general structure of society, however, does not often permit such open communication. Feelings are hurt, relationships are ruptured, misunderstandings arise, and eventually, communication ceases. In simple, clear language we describe the therapy group as a social laboratory in which such honest interpersonal exploration is not only permitted but encouraged. If people are conflicted in their methods of relating to others, then a therapy group provides a precious opportunity to learn many valuable things about themselves. We emphasize that working on their relationships directly with other group members will not be easy; in fact, it may even be stressful. But if they can completely understand and work out their relationships with the other group members, there will be an enormous carryover into their outside world: they will discover pathways to more rewarding relationships with significant people in their life now and with people they have yet to meet. We remind clients not to be discouraged when their familiar patterns emerge in the group. What happens in the group mirrors life, but now with an opportunity to achieve a different outcome. We advise members that the way to use therapy best is to be honest and direct with their immediate feelings in the group, especially their feelings toward the other group members and the therapists. Over and over again, we emphasize this point, referring to it as the core of group therapy. We point out that the group is not a forced confessional; members have different rates of developing trust and revealing themselves. The group therapy benefits from members’ risk-taking, and we urge members to try new types of behavior in the group setting. We predict certain stumbling blocks and warn clients that they may feel puzzled and discouraged in the early meetings. At times they will not understand how working on group problems and intermember relationships can be of value in solving the problems that brought them to therapy. This puzzlement, we stress, is to be expected in the typical therapy process. We tell them that many people at first find it painfully difficult to reveal themselves or to express positive or negative feelings, and members need to resist the tendency to withdraw emotionally, hide feelings, and let others do the work of expressing feelings. We also predict that they are likely to develop feelings of frustration or annoyance with the therapist, who may not be able to supply answers to many of their questions. Help will often be forthcoming from other group members, though at the onset of the group it may be difficult to accept this fact. For clients entering an open-ended psychotherapy group, we emphasize that the therapeutic goals of group therapy are ambitious, because we are attempting to change behavior and attitudes many years in the making. Treatment is therefore gradual. We strongly urge clients to stay with the group and to ignore any inclination to leave it before giving it a real chance. It is almost impossible to predict the eventual effectiveness of a group during the first dozen meetings. Thus, we urge clients to suspend judgment and to make a good-faith commitment to participate in at least twelve meetings before even attempting to evaluate the ultimate usefulness of the group. For clients who are entering a briefer group therapy, we say that the group offers an outstanding opportunity to do a piece of important work upon which to build in the future. Each session is precious, and it is in their interest and the interest of the other group members to attend each session. It is vitally important for the therapist to raise expectations, to instill faith in group therapy, and to dispel the false notion that group therapy is second-class therapy. Research tells us that clients who enter therapy expecting it to be successful will exert much greater effort in the therapy, will develop a stronger therapeutic alliance, and are significantly more likely to succeed.74 This effect of client pretherapy expectancies is even greater for less structured therapies that may generate more client anxiety and uncertainty.75 Therefore, we provide a brief description of the history and development of group therapy—how group therapy passed from a stage during World War II, when it was valued for its economic advantages (that is, it allowed psychotherapists to reach a large number of people in need), to its current position in the field, where it clearly has unique features to offer and is the treatment of choice for many individuals. We will add some background about our professional experience and expertise and why we believe this approach could be of value to the client and compare it to alternative treatments. We inform clients that psychotherapy outcome studies demonstrate that group therapy is as efficacious as any mode of individual therapy. We may refer them to websites such as the American Group Psychotherapy Association, which provides accessible information for consumers. Articles written independently about group therapy by group therapy participants can be particularly impactful.76 There are a few ground rules. Nothing is more important than honestly sharing perceptions and feelings about oneself and other members in the group. Confidentiality is as essential in group therapy as it is in any therapist-client relationship. For members to speak freely, they must have confidence that their statements will remain within the group. In our decades of group therapy experience, we can scarcely recall a single harmful breach of confidence and can therefore reassure group members on this matter. But the literature does report that this occurs. Ethical practice requires therapists to note that the group members, unlike the therapists, are not legally bound to confidentiality.iii In most jurisdictions, disclosure in group therapy does not have the protection of a privileged communication, as is the case in individual therapy, on account of the presence of other group members. A related point is that in light of ever-increasing attention to client privacy and the stringent protections regarding client health information, we should obtain formal client consent to discuss their personal issues in the group at our therapeutic discretion, when indicated and necessary, including when the client may be absent from a session. This consent also includes communication with other providers and team members if the client is in concurrent treatment.77 It is important not to corrode client trust regarding confidentiality. However, at the same time, we must also inform the client of mandatory professional reporting obligations.78 In virtually all jurisdictions the therapist must report situations in which the actions of the client are, or will imminently be, harmful to self or others. These situations may involve child mistreatment or abuse or sexual abuse of a client by a health-care professional.79 Occasionally, members may inquire whether they can relate aspects of the group therapy discussion with a spouse or a confidant. We urge them to discuss only their own experience: the other members’ experiences, and certainly their names, should be kept in strictest confidence. In addition to the ground rules of honesty and confidentiality, we make a point of discussing the issue of contacts outside the group between members, which, in one form or another, will occur in every psychotherapy group. Two particularly important points must be stressed. First, the group provides an opportunity for learning about one’s problems in social relationships, and it is not an assembly for meeting and making social friends. Indeed, if the group is used as a source of friends it loses its therapeutic effectiveness. In other words, the therapy group teaches one how to develop intimate, long-term relationships, but it does not provide these relationships. It is a bridge, not the destination. Expect some clients to resist this. In groups that have been meeting for some weeks, we have had group clients say that they have never before felt such a close connection with another person, and they are frustrated by the limits this contract imposes. It can be helpful to underscore that they have achieved the kind of closeness they thought would never happen—now the task is to learn as much as possible about how they created that and how they can replicate it with others outside the group. If, by chance or design, however, members do meet outside the group, it is their responsibility to discuss the salient aspects of that meeting inside the group. It is particularly useless for therapists to prohibit extragroup socializing. Almost invariably during the therapy, group members will engage in some outside socializing, and in the face of a therapist’s prohibition they may be reluctant to disclose it in the group. As we shall elaborate in Chapter 10, extragroup relationships are not harmful per se (in fact, they may be extremely important in the therapeutic process); what impedes therapy is the conspiracy of silence that often surrounds such meetings. An approach of injunction and prohibition merely draws group members into the issue of rule setting and rule breaking. It is far more effective to explain why certain actions may interfere with therapy. With subgrouping, for example, we explain that friendships among group members often prevent them from speaking openly to one another in the group. Members may develop a sense of loyalty to a dyadic relationship, and may thus hesitate to betray the other by reporting their conversations back to the group. Yet such secrecy will conflict with the openness and candor so essential to the therapy process. This is a particular challenge in day treatment and partial hospitalization programs in which clients may see one another throughout the day. The primary task of therapy group members is, we remind them, to learn as much as possible about the way each individual relates to each other person in the group. Secrets and private alliances obstruct that goal and render the treatment less effective by creating a tentativeness or guardedness in communication. Secrets may even place some clients at risk if there are covert conversations about self-harm. Occasionally group members may wish to make a secret disclosure to the group leader. It is almost always best for the disclosure to be shared with the group. Group leaders must never agree to secrecy in advance but should instead promise to use discretion and their best clinical judgment. There is an important corollary. Group leaders who, in the pregroup assessment, have obtained pertinent information about a client who resists sharing in the group should not introduce that material without client permission. You may urge, encourage, even cajole the client, you may even point out the negative effects of the client withholding pertinent information, but you cannot take the step of unilaterally overriding the client’s objection; doing so will damage the alliance and may well be a professional ethics violation. This strategy of providing full information to the members about the effects of secretiveness, subgrouping, and extragroup socializing provides the therapist with far greater leverage than the strategy of the ex cathedra “thou shalt not.” If group members engage in secretive subgrouping, you do not have to resort to the ineffectual “Why did you break my rules?” Instead you can plunge into the heart of resistance by inquiring, “How come you’re sabotaging your own therapy?” Thus far, we’ve emphasized content in our pregroup preparation of clients. We may augment that through the use of a printed handout. But we can also address the underlying process that may occur during the preparation meeting. The divergent responses clients have to the exact same preparation session can be illuminating with regard to key interpersonal processes. This can be particularly vivid when they are juxtaposed one after another in pregroup sessions led by the same co-therapy team. > After going through the content of the preparation session, Shelley, a fifty-year-old woman with a history of chronic depression and social anxiety, commented, “I so appreciate your diligence around the entry and preparation for people into the group. I take it as a sign of how serious an undertaking this is, and it increases my sense of hope about it helping me; I feel valued and cared for.” The co-therapists welcomed her spontaneous feedback and noted that she was already addressing her stated goals of taking more interpersonal risks and moving into the center of her life from the sidelines she typically inhabits.

In the very next hour, the two therapists had a preparation session with Norma, a forty-year-old single mother, also with chronic depression, who characteristically adopted a harsh, judgmental stance. She expected people to fall short and to disappoint her. Her dismissive and irritable stance throughout the preparation session was palpable, and when we asked her how the session was for her, she responded with, “Why are you wasting time doing this? You haven’t told me anything that I can’t read myself in the handout. Why all the rigmarole?”

The co-therapists both felt rebuked and diminished but recalled that Norma had stated that one of her goals in therapy was “learning what I do that pisses off so many people around me.” One of the therapists commented that Norma seemed irritated with them, and Norma apologized for being so critical, stating that she realized the therapists were trying to be helpful. She also requested that they not just give her feedback about what she did wrong, but also try to help her change. << In summary, this cognitive approach to group therapy preparation has several goals: to provide a rational explanation of the therapy process; to describe what types of behavior are expected of group members; to establish a contract about attendance; to raise expectations about the effects of the group; and to predict (and thus to ameliorate) problems and discomfort in early meetings. Underlying the therapists’ words in the preparation session is a process of demystification. Therapists convey the message that they respect the client’s judgment and intelligence; that therapy is a collaborative venture; and that leaders are experts who operate on a rational basis and are willing to share their knowledge with the client. One final point is that comprehensive preparation also enables the client to make an informed decision about entering a therapy group. Though much of this discussion is geared toward preparing clients for a long-term interactional group, its basic features may be adapted to any other type of group therapy. Brief therapy groups that rely on different therapeutic factors—for example, cognitive-behavioral groups—would require a presentation with altered details. But every therapy group profits from the preparation of its members. If clinical exigencies preclude a thorough preparation, then a short preparation is better than none at all. In Chapter 15, we describe a three-minute preparation offered at the start of an acute inpatient group. Other Approaches to Preparation Straightforward cognitive preparation presented to a client only once may not be sufficiently powerful. Clients are anxious during their pregroup interviews and often recall astonishingly little of the content of the therapist’s message, or grossly misunderstand key points. For example, some group participants whom we asked to remain in the group for twelve sessions before evaluating its usefulness understood us to say that the group’s entire life span would be twelve sessions. Consequently, it is necessary to repeat and to emphasize deliberately many key points of the preparation both during the pregroup sessions and during the first few sessions of the group. One example: For my outpatient groups that met once a week, the weekly written summary I (IY) sent out to all the group members after each session provided an excellent forum in which to repeat essential parts of the preparation procedure. Many therapists have described other methods of increasing the potency of the preparatory procedure. Some therapists have used another group member to orient and prepare a new member.80 This can work well in day treatment programs. Others have used a written document for the new client to study before entering a group. In agency settings, detailed handouts can be prepared for prospective clients. In settings with long waiting lists for treatment and limited scope for preparation sessions, clients can be asked to attend a pregroup meeting focused on orientation and preparation. We can add further impact by including written handouts here as well, perhaps even with testimonials from former participants of the group program (identities concealed of course).81 Adding a “Frequently Asked Questions” section can be very helpful. It is important to adapt materials to the culture of the community being served. In short, know your objectives and recognize that there is room to be creative. The appendix to this book contains a model of a handout for group therapy preparation. Other preparation techniques include observation of an audiotape or videotape of meetings. For reasons of confidentiality, this must be a professionally marketed tape in the public domain or a tape of a simulated group meeting with staff members or professional actors playing the roles of members. The scripts may be deliberately designed to demonstrate the major points to be stressed in the preparatory phase. The video “Group Therapy: A Live Demonstration” can be used in this way.82 Orientation videos to group therapy are now also available and provide an enlivened introduction to group therapy.83 A 2018 study utilized client responses on the Group Therapy Questionnaire (GTQ) to identify negative attitudes and expectations about group therapy. The importance of aligning client goals with the group format and group therapy expectations was then discussed in a tailored one-hour pregroup orientation group meeting, after which clients were placed into CBT therapy groups. These pregroup preparation groups improved participation and attendance rates.84 An even more powerful mode of preparing clients is to provide them with personal training in desired group behavior.85 Several experiential formats have been described. One brief group therapy team employs a two-part preparation. First, each group member has an individual meeting to establish a focus and goals for therapy. Afterward, prospective group members participate in an experiential single-session workshop at which eighteen to twenty clients perform a series of structured exercises that promote interaction and discussion of the experience, some involving dyads, some triads, and some the entire group.86 Another study used four preparatory sessions, each of which focused on a single concept of pregroup training: (1) using the here-and-now, (2) learning how to express feelings, (3) learning to become more self-disclosing, and (4) becoming aware of the impact one has and wishes to have on others. The researchers handed out didactic material in advance and designed structured group exercises to provide experiential learning about each concept.87 Other projects use role playing to simulate group therapy interaction.88 In general, the more emotionally alive and relevant the preparation is, the greater its impact will be. Some research suggests that it is the active, experiential aspect of the pretraining, rather than the cognitive or passive, observer aspect, that may have the greatest impact.89 Much current preparation research focuses on the client’s motivation and change readiness.90 The focus on motivation as a target for intervention (rather than as a prerequisite for treatment) originated in the treatment of addiction and has subsequently been applied effectively for clients with eating disorders and perpetrators of sexual abuse—clinical populations in which denial and resistance to change is endemic.91 These resistances do not dissipate readily; they require ongoing attention. Interventions that promote client motivation, such as motivational interviewing, can be readily integrated into many models of group therapy by focusing attention on the gap between the client’s preferred way of being and their actual behaviors.92 In the future, we can expect interactive computer technology to generate even more effective preparatory programs. However, the existing approaches, used singly or in combination, can be highly effective. Consistent research evidence, to which we now turn, attests to the general effectiveness of these techniques. Research Evidence on Pregroup Preparation In a controlled experiment, my (IY) colleagues and I tested the effectiveness of a brief cognitive preparatory session.93 Of a sample of sixty clients awaiting group therapy, half were seen in a thirty-minute preparatory session, and the other half were seen for thirty minutes in a conventional interview dedicated primarily to history-taking. Six therapy groups (three of prepared clients, three of unprepared clients) were organized and led by group therapists who were unaware that there had been an experimental manipulation. (The therapists believed only that all clients had been seen in a standard intake session.) A study of the first twelve meetings demonstrated that the prepared groups had more faith in therapy than the unprepared groups and engaged in significantly more group and interpersonal interaction, and that this difference was as marked in the twelfth meeting as in the second.94 We know that increased faith in therapy translates to improved outcomes. Moreover, the research design required that identical preparation be given to each participant. Had the preparation been more thorough and more individualized for each client, its effectiveness might have been even greater. The basic design and results of this study—a pregroup preparation sample, which is then studied during its first several group therapy meetings and shown to have a superior course of therapy compared with a sample that was not properly prepared—has been replicated many times. The clinical populations have varied, and particular modes of preparation and process and outcome variables have grown more sophisticated. But the amount of corroborative evidence supporting the efficacy of pregroup preparation on both group processes and client outcomes is impressive.95 Furthermore, few studies fail to find positive effects of preparation on clients’ work in group therapy.96 In fact, an extensive literature review concluded that proper pregroup preparation is a cornerstone of evidence-based group therapy.97 Virtually all the research demonstrates the beneficial impact of preparation on client participation. A direct effect on global client outcome is more difficult to demonstrate, however, because the contributions of other important therapy variables obscure the effects of preparation.98 For those readers who wish to explore the research we have summarized the studies below. Pregroup preparation improves attendance99 and increases self-disclosure, self-exploration, and group cohesion,100 although the evidence for lower dropout rates is less consistent.101 Prepared group members express more emotion than unprepared members;102 assume more personal responsibility in a group;103 disclose more of themselves;104 show increased verbal, work-oriented participation;105 are better liked by the other members;106 report less anxiety;107 are more motivated to change;108 show a significant decrease in depression;109 improve in marital adjustment and ability to communicate;110 are more likely to attain their primary goals in therapy;111 and have fewer erroneous conceptions about the group procedure.112 Even notoriously hard-to-engage populations, such as domestic abusers, respond very positively to measures aimed at enhancing attendance and participation.113 Some Final Comments on Pregroup Preparation The first meetings of a therapy group are both precarious and vitally important. Many members grow unnecessarily discouraged and terminate therapy, and the group is in a highly fluid state and maximally responsive to the influence of the therapist—who has the opportunity to help the group elaborate therapeutic norms. The early meetings are a time of considerable client anxiety—both intrinsic, unavoidable anxiety and extrinsic, unnecessary anxiety. Preparation can assist in both domains. Intrinsic anxiety issues from the very nature of the group. Individuals who have encountered lifelong disabling difficulties in interpersonal relationships will invariably be stressed by a therapy group that demands not only that they attempt to relate deeply to other members but also that they discuss these relationships with great candor. In group therapy, anxiety arises from interpersonal conflict as well as from dissonance springing from one’s desire to remain in the group while at the same time feeling highly threatened by the group task. An imposing body of evidence demonstrates that there are limits to the adaptive value of anxiety in therapy.114 An optimal degree of anxiety enhances motivation and increases vigilance, but excessive anxiety will obstruct one’s ability to cope with stress. In his masterful review of the evidence supporting the innate human pursuit of mastery of one’s environment, Robert White noted that excessive anxiety and fear are the enemies of environmental exploration; they impede learning and decrease exploratory behavior in proportion to the intensity of the fear.115 In group therapy, crippling amounts of anxiety may prevent the introspection, interpersonal exploration, and testing of new behavior essential to the process of change. Much of the anxiety experienced by clients early in the group is not intrinsic to the group task but extrinsic, unnecessary, and sometimes iatrogenic. This anxiety is a natural consequence of being in a group situation in which one’s expected behavior, the group goals, and their relevance to one’s personal goals are exceedingly unclear. Effective preparation for the group will reduce the uncertainty and the accompanying extrinsic anxiety by clarifying the group goals, by explaining how group and personal goals are confluent, by presenting unambiguous guidelines for effective behavior, and by providing the client with an accurate formulation of the group process. Standards of practice add another essential component to preparation. Informed consent is particularly important. Contemporary therapists are increasingly required to document that they have provided sufficient information to their clients about treatment benefits, side effects, costs, and alternatives so that clients can make informed choices about their therapy.116 Informed consent cannot be dispensed with in a single discussion but must be revisited on a timely basis. Obtaining informed consent is a standard of practice enshrined in the Ethics Guidelines of the American Psychological Association, the American Group Psychotherapy Association, and the American Psychiatric Association.117 Rather than resisting it as one more bureaucratic intrusion, therapists should recognize that periodic frank discussions about the course of therapy convey respect for the client and strengthen the therapeutic alliance. This type of communication, in turn, sets the stage for effective group work. Footnotes i One is reminded of the farmer who attempted to train his horse to do with smaller and smaller amounts of food, but eventually lamented, “Just as I taught it to manage with no food at all, the darn critter went and died on me.” ii It is for this very reason that I (IY) decided to write a group therapy novel, The Schopenhauer Cure (New York: HarperCollins, 2005), in which I attempt to offer an honest portrayal of the effective therapy group in action. We subsequently adapted the novel into a comprehensive training video about group psychotherapy. See I. Yalom and M. Leszcz, “Group Therapy: A Live Demonstration,” 2011, available at www.agpa.org. iii The limits of confidentiality in group therapy is an area that has only recently been explored in the professional literature. There are reports of co-members being called to testify in criminal or civil proceedings, but these are extremely rare. image1

Psychoeducational Group for Sexual Assault Survivors with PTSD

Abraham De La Cruz
Doctorate of Education- Community Care and Counseling-
Marriage and Family, Liberty University
EDCO 711: Advanced Group Counseling
Prof. Dr. Gregory Mears

April 06, 2025

Introduction

Psychoeducational group for trauma survivors

Supporting sexual assault PTSD recovery

Introductory session establishes a safe space

Combines evidence-based therapeutic techniques

Integrates peer support with education

Honors individual healing journey timelines

Welcome to this psychoeducational group, designed to support sexual assault survivors struggling with PTSD symptoms. This initial session establishes a safe, supportive environment where members can start healing. The group combines evidence-based clinical practices and supportive peer connections to support members in overcoming the unique challenges trauma survivors face. This session focuses on building trust, educating members about PTSD, and learning practical coping skills. We create an environment where members are heard and empowered, reassuring them that healing is possible and takes time and support (Ikechukwu, 2024). The session combines clinical and spiritual components to heal the whole person—mind, body, and spirit. Members leave with more knowledge of their symptoms, skills to manage distress, and connections to peers who get it. The group honours the courage to seek help and values each member’s healing journey. The format combines education, skills, and processing to support members where they are on their healing journey.

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Session Objectives

This session has six clear objectives to guide our time together. The first thing we will do to support participants will be to help them recognize common PTSD symptoms like flashbacks, hypervigilance, and emotional numbness. When the patient understands these as normal trauma responses, shame and self-blame are reduced. Secondly, I will discuss how trauma affects brain functioning. For example, fear responses are regulated by the amygdala, and the prefrontal cortex has trouble regulating itself. Third, participants will learn and rehearse how to ground to manage dissociation or panic at the moment. These concrete tools act to alleviate distressing episodes immediately. The fourth will be to look at the concept of cognitive restructuring (how to spot and disprove if they no longer serve the trauma) thought patterns. Next, we will establish group rules to feel physically and emotionally secure during our sessions. Moreover, we will finally develop covenants between members since shared experiences tend to reduce isolation and shame. Together, these objectives form a foundation for healing education, practical skills, and community support
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Define PTSD symptoms and diagnostic criteria.

Explain trauma’s impact on brain function.

Teach grounding techniques for emotional regulation.

Introduce cognitive restructuring for negative thoughts.

Establish group norms for emotional safety.

Encourage peer support through shared experiences.

Planned Activities

Our session includes six carefully planned activities to engage participants at multiple levels. The “Two Truths and a Hope” icebreaker promotes members sharing safely while highlighting possibilities rather than trauma stories. The mini-lecture provides essential psychoeducation about PTSD symptoms and trauma neurobiology, validating participants’ experiences. Through the practice of the grounding technique, members learn and immediately apply an easy yet powerful tool to manage distress, enhancing the likelihood of applying the skill outside the group. The discussion in the smaller group offers a safe place where participants may share coping skills within smaller surroundings, often feeling safe to share first. The reflection exercise helps each participant clarify personal healing goals, making the group experience more personally relevant. We conclude with an encouraging scripture to provide spiritual support and reinforce hope. Each activity flows naturally to the next, keeping participants active while respecting emotional boundaries. The variability—from didactic to experiential to reflective—includes different learning modes and comfort levels.

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Icebreaker: “Two Truths and a Hope.”

Mini-lecture: PTSD symptoms and trauma science.

Grounding technique demonstration and practice.

Small-group discussion: Coping strategies.

Reflection: Personal goals for healing.

Closing: Encouragement verse (Psalm 34:18).

Mini-Lecture Outline
Definition: PTSD per DSM-5.

Prevalence: Sexual assault survivors.

Symptoms: Intrusive memories, avoidance.

Neurobiology: Amygdala hyperactivity.

Coping: Grounding, CBT, support.

Hope: Recovery is achievable.

The mini-lecture provides crucial psychoeducation in digestible segments. First, about current diagnostic criteria, we define PTSD as a normal reaction to abnormal events. Participants understand through statistics of sexual assault survivors that they are not alone in their struggles. Three symptom clusters, re‐experiencing, avoidant and hyperarousal, are further explained through examples that corroborate members’ experiences. It briefly explains the neurobiology in that trauma affects brain structures, and de-personifying the symptoms as biological responses and not personal failure is helpful. However, the amygdala is overactive, leading to false alarms, whereas the prefrontal cortex underachieves when responding to regulate emotion (Cleo, 2023). It adds the coping section, which explains three evidence-based approaches: grounding techniques for short-term relief, cognitive approaches for long-term change, and the importance of social support. Finally, we bring hope with recovery statistics and neuroplasticity, which is the brain’s ability to heal. The balanced presentation of this does not fall into the pitfall of barraging readers with scientific jargon yet gives enough detail to dispel common misconceptions related to PTSD.

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Tentative Schedule

The session is structured but flexible to maximize engagement and emotional safety. First, there is a 10-minute welcome where everyone is introduced, an icebreaker activity is done, and the group environment is slowly being eased into. The 15-minute mini-lecture will provide essential psychoeducation to those participants who are still fresh and attending. Fifteen minutes of practice for the grounding technique is provided, and there is a demonstration, group participation, and questions. The hands-on part in this component helps to actively learn this skill. After that, the 15-minute small group discussion has a more intimate setting for people to share coping strategies once some initial rapport is built. The final 5 minutes are reserved for closing reflections and a hopeful scripture that positively concludes the session, emphasizing safety and purpose. The educational and participatory segments are interchanged to prevent emotional overload. They are time estimates; we will monitor the group’s energy and adjust as dictated if necessary, never at the expense of emotional safety any time at the expense of the clock. Mental resetting is allowed by brief transitions between activities. It starts and ends with low-intensity activities; the most challenging content is placed in the middle when the group is most cohesive.

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0–10 mins: Welcome and icebreaker.

10–25 mins: Mini-lecture.

25–40 mins: Grounding practice.

40–55 mins: Small-group discussion.

55–60 mins: Closing reflection.

Group Rules & Confidentiality
at all times.

Respect others’ experiences and boundaries.

Participate at your comfort level.

No judgment or unsolicited advice.

Report safety concerns to the leader.

Maintain strict confidentiality

Silence phones to minimize distractions.

Establishing clear group rules is the first step in creating a safe therapeutic environment. Explicit guidelines on what can and cannot be shared outside the group form the base for confidentiality. Although members should be able to discuss their experiences, they will never reveal another’s experiences or identities. It also includes respecting others by valuing their perspectives, not interrupting, and using words wisely to avoid upsetting someone else. The voluntary participation rule means no one has to feel under the gun to share what she’s been through; silence is always an option. The no-judgment guideline also extends to verbal as well as non-verbal responses since trauma survivors are super sensitive to people’s facial expressions or their body language (Nutter, 2023). Safety protocols spell out mandatory reporting requirements in a way that no alarm whatsoever supports members’ primacy over wellbeing. Reduces disruptions that could break the group’s emotional focus on the job. Finally, presented as a set of collaborative commitments as opposed to restrictions, members can suggest additions or seek clarification. We will post the rules visibly each session as a reminder.

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Biblical Integration

Scriptural integration provides spiritual grounding to those searching for meaning through faith. Psalm 34:18 does acknowledge the presence of suffering and affirms the presence of God amidst suffering. Isaiah 41:10 assures help from God when the survivor feels most exposed. The 2 Corinthians reading emphasizes how healing wounds can become a source of support to others and affirms the group’s shared experience. Romans 8:28 offers the possibility of meaning-making after trauma without denying the suffering. Philippians 4:6-7 provides prayer as an everyday means of handling worry and finding inner peace. John 16:33 realistically acknowledges the troubles of life and provides ultimate hope. These verses are selected to avoid the easy “quick fix” theology and instead meet the survivors where they are hurt and point toward healing. The biblical integration is made optional so that participants may take from them that which speaks to them spiritually without feeling bound to conform.

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Psalm 34:18 – God’s nearness in pain

Isaiah 41:10 – Divine strength in weakness

2 Corinthians 1:3-4 – Comfort to share comfort

Romans 8:28 – Purpose in healing

Philippians 4:6-7 – Peace through prayer

John 16:33 – Overcoming trauma with hope

Coping Strategies
Grounding: 5-4-3-2-1 technique

Mindfulness: Breath-focused meditation

Journaling: Trauma narrative exercises

Cognitive Restructuring: Challenging negative beliefs

Social Support: Peer validation

Self-Care: Sleep, nutrition, routine

The participants will learn six evidence-based coping strategies to manage the symptoms of PTSD. Flashbacks or panic can be relieved immediately using the 5-4-3-2-1 grounding technique that stimulates the five senses to reconnect you to the current moment. Mindfulness breathing exercise is a way of managing or regulating the stress response of the nervous system and creating what I call ‘space’ between the triggers and the reactions (Brems, 2024). Journaling is a place outside of oneself to work things out, with optional prompts just in case. Cognitive restructuring enables someone to reframe automatic negative thoughts such as “It was my fault” that are likely to follow trauma. Social support strategies concentrate on constructing healthy connections and putting boundaries in place with unhelpful relationships. Necessities such as Sam’s Daily Discipline around sleep patterns and nourishing meals that greatly affect emotional regulation make up self-care. The strategies are presented as experiments rather than requirements since different approaches work for different people. In addition, participants will receive take-home descriptions of each technique with space to note the ones they want to practice.

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Trauma’s Neurobiological Impact
Amygdala: Hyperactive threat detection

Hippocampus: Impaired memory processing

Prefrontal Cortex: Reduced regulation

Stress Hormones: Chronic cortisol release

Neural Pathways: Maladaptive rewiring

Healing: Neuroplasticity potential

Understanding trauma’s physical effects on the brain demystifies symptoms of PTSD. Hyperactivity of the amygdala explains hypervigilance and scanning for danger even when safe. Alterations to the hippocampus explain traumatic memories as fragmented or intruding unexpectedly. The compromised function of the prefrontal cortex explains difficulty concentrating or making decisions under duress. The chronic release of cortisol explains how the body remains locked up and fighting or freezing long after the danger is past (de Kloet & Joëls, 2023). Maladaptive rewiring explains how neural circuits formed during trauma continue to misfire. Neuroplasticity offers the most promise – the brain can build new, healthier connections through practice and therapy, much as the muscles build up through exercise. This psychoeducation makes symptoms understandable as biological responses and not personal weaknesses or character flaws. We use simple comparisons like an alarm system that’s too sensitive or a computer frozen in a loop to simplify complex concepts. Visual aids show scans of healthy versus trauma-brained brains, making the invisible become visible. Many participants are relieved that their reactions are due to physical causes, not personal failure.

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Sample Discussion Questions
How has PTSD impacted daily life?

What coping skills have you tried?

What support do you wish you had?

How can this group help you heal?

What gives you hope?

What self-care practice will you try?

The discussion questions are crafted very carefully for several therapeutic uses. The first question about PTSD’s impact allows its members to share their encounters with PTSD and realize that people are going through similar problems as them. The second question about coping skills assumes that coping skills may exist and be strengthened or acquired from each other’s strategies. The third question regarding desired support addresses any unmet needs the group can service. The fourth question asks the members to participate in their healing process by posing how they would like to use the group. The fifth hope inquiry turns towards believing about the future. Finally, the question of self-care talks about planning between session applications in a concrete manner. All questions are open-ended to accommodate the responses at different comfort levels. They work through the natural arc of therapy reflected on past experiences, the present and the future. They were designed to avoid ‘why’ phrasing that tends to be accusatory and used instead of ‘how’ and ‘what’ for non-accusatory exploration. If you cannot say what you want, we will give examples of how you could respond to ease other people’s tension. An answer may be verbal or answered in writing, depending on the member’s pleasure.

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Reference
Brems, C. (2024). Understanding the Psychology of Breath and Breathing. Therapeutic Breathwork, 127–171. https://doi.org/10.1007/978-3-031-66683-4_4
Cleo, P. (2023). College Experiences of Female Students with Posttraumatic Stress Disorder – ProQuest. Proquest.com. https://www.proquest.com/openview/da75a627861e524bbfae5b6c6385af81/1?cbl=18750&diss=y&pq-origsite=gscholar
de Kloet, E. R., & Joëls, M. (2023). The cortisol switch between vulnerability and resilience. Molecular Psychiatry. https://doi.org/10.1038/s41380-022-01934-8
Ikechukwu, N., Godspower. (2024, July 2). Integrating Indigenous Cultural Values and Sustainable Architecture for Healing and Empowerment. Scholaris.ca. https://ucalgary.scholaris.ca/items/231b8d27-15c6-44be-9814-16a0c68ca3b0
Nutter, M. (2023). Developing Resilience In The School Setting: A Response To Trauma. Sycamore Scholars. https://scholars.indianastate.edu/etds/6/

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Psychoeducational Group Plan: Supporting Sexual Assault Survivors with PTSD

Abraham De La Cruz
Doctorate of Education-Community Care and Counseling-
Marriage and Family, Liberty University
EDCO 711: Advanced Group Counseling
Prof. Dr. Gregory Mears
March 23, 2025

I. Subject Synopsis

Members of psychoeducational groups can learn more about a specific issue, problem, or worry; develop their interpersonal skills and self-awareness; and improve their ability to comprehend and resolve issues that impact them (Brown, 2018). The purpose of this psychoeducational group is to assist survivors of sexual assault who are suffering from post-traumatic stress disorder (PTSD). The main goals will be to educate people on PTSD symptoms, coping mechanisms, and resilience building. Numerous evaluations have shown that sexual assault is linked to an increased risk of being diagnosed with conditions such as acute stress disorder (ASD), post-traumatic stress disorder (PTSD), and symptoms of PTSD (Stockman et al., 2023). Psychoeducational interventions have been shown to statistically significantly improve PTSD and depression in survivors and can significantly improve coping mechanisms, including trauma-focused therapy interventions like cognitive processing and exposure therapy (Heard & Walsh, 2023). To empower members, this group will apply evidence-based practices such as mindfulness, cognitive-behavioral approaches, and peer support.

According to Moring et al. (2023), giving patients psychoeducation before to starting CPT might boost their expectations, optimism, and perception of the therapy’s legitimacy—all of which are essential for the best possible outcome. This group will be set up to provide a secure and encouraging setting where members may learn how to control their symptoms and enhance their quality of life. According to Brown (2018), members may experience significant feelings of guilt, wrath, resentment, and other upsetting emotions as a result of personal shortcomings and may blame others or themselves for what occurred to them. This group is extremely significant in the counseling industry since survivors of sexual assault frequently suffer from PTSD.

II. Group Outline

A. Group Purpose:

· To give survivors of sexual assault psychoeducation on PTSD symptoms and coping techniques.

· To promote self-efficacy and emotional resilience using evidence-based practices.

· To establish a secure environment where survivors may talk about their experiences and get assistance from their peers. These groups can offer a secure setting where people can freely express unpleasant and upsetting emotions (Brown, 2018).

B. Target Audience:

· Adult survivors of sexual assault have been diagnosed with or are suffering symptoms of PTSD.

· Individuals seeking formal direction and assistance during their recovery process.

· Participants are willing to participate in psychoeducational activities and conversations.

C. Goals:

1. Improve participants’ awareness of PTSD’s effects on mental health and daily life.

2. Provide participants with appropriate coping skills for managing PTSD symptoms and enhancing emotional control.

D. Objectives:

1. At the end of the group, participants will be able to recognize three typical PTSD symptoms and psychological repercussions.

2. Participants will grasp how trauma impacts cognitive and emotional processing.

3. Participants will learn and practice at least three evidence-based coping methods to manage PTSD symptoms, such as grounding techniques, mindfulness, and cognitive restructuring. According to Heard and Walsh (2023), these techniques help to reduce PTSD symptoms and improve coping skills.

4. Participants will develop a tailored coping strategy with at least three methods for high-stress situations.

E. Group Rules:

Heard and Walsh (2023) argue that activities to build trust and group norms are essential for effective treatments.

1. Confidentiality: To create a secure and trustworthy atmosphere, all group talks are kept 

2. private.

3. Respect: Participants will acknowledge each other’s experiences, viewpoints, and limits.

4. Supportive, non-judgmental environment for healing and growth. Participation: Members are urged to participate while maintaining their comfort levels.

5. Safety: Any reports of injury to self or others will be handled following ethical and legal 

standards.

6. A major ethical concept is to do no damage; while this may seem straightforward, it is 

not, and group leaders must be cognizant of ethical standards to monitor the potential for 

harm (Brown, 2018).

F. Biblical Integration:

·
Psalm 34:18: “The Lord is close to the brokenhearted and saves those who are crushed in spirit.” This scripture stresses God’s compassion and consolation for people who are suffering.

·
Isaiah 41:10: “So do not fear, for I am with you; do not be dismayed, for I am your God. I will strengthen and help you and uphold you with my righteous right hand.” This scripture reassures survivors that they are not alone in their healing journey.

· The Christian values of hope, restoration, and support will be used to promote faith-based healing and resilience.

References

Brown, N. W. (2018). Psychoeducational Groups, 4th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9781351689410Heard, E., & Walsh, D. (2023). Group Therapy for Survivors of Adult Sexual Assault: A Scoping Review. 
Trauma, Violence & Abuse, 
24(2), 886–898.

https://doi.org/10.1177/15248380211043828

Heard, E., & Walsh, D. (2023). Group Therapy for Survivors of Adult Sexual Assault: A Scoping Review. 
Trauma, Violence & Abuse, 
24(2), 886–898. https://doi.org/10.1177/15248380211043828

King James Bible Version. (2025). KJV Online. https://www.kingjamesbibleonline.org/

Moring, J. C., Peterson, A. L., Straud, C. L., Ortman, J., Mintz, J., Young, M. S., McGeary, C. A., McGeary, D. D., Litz, B. T., Macdonald, A., Roache, J. D., Resick, P. A., & for the STRONG STAR Consortium. (2023). The interactions between patient preferences, expectancies, and stigma contribute to posttraumatic stress disorder treatment outcomes. 
Journal of Traumatic Stress, 
36(6), 1126–1137. https://doi.org/10.1002/jts.22982

Stockman, D., Haney, L., Uzieblo, K., Littleton, H., Keygnaert, I., Lemmens, G., & Verhofstadt, L. (2023). An ecological approach to understanding the impact of sexual violence: a systematic meta-review. 
Frontiers in Psychology, 1–16. https://doi.org/10.3389/fpsyg.2023.1032408