The Theory and Practice of Group Psychotherapy (13 page)

I have listed these four levels in the order of degree of inference. An unfortunate and long-standing conceptual error has resulted, in part, from the tendency to equate a “superficial-deep” sequence with this “degree of inference” sequence. Furthermore, “deep” has become equated with “profound” or “good,” and superficial with “trivial,” “obvious,” or “inconsequential.” Psychoanalysts have, in the past, disseminated the belief that the more profound the therapist, the deeper the interpretation (from the perspective of early life events) and thus the more complete the treatment.
There is, however, not a single shred of evidence to support this conclusion.

Every therapist has encountered clients who have achieved considerable genetic insight based on some accepted theory of child development or psychopathology—be it that of Freud, Klein, Winnicott, Kernberg, or Kohut—and yet made no therapeutic progress. On the other hand, it is commonplace for significant clinical change to occur in the absence of genetic insight. Nor is there a demonstrated relationship between the acquisition of genetic insight and the persistence of change. In fact, there is much reason to question the validity of our most revered assumptions about the relationship between types of early experience and adult behavior and character structure.
⁵²

For one thing, we must take into account recent neurobiological research into the storage of memory. Memory is currently understood to consist of at least two forms, with two distinct brain pathways.
⁵³
We are most familiar with the form of memory known as “explicit memory.” This memory consists of recalled details, events, and the autobiographical recollections of one’s life, and it has historically been the focus of exploration and interpretation in the psychodynamic therapies. A second form of memory, “implicit memory,” houses our earliest relational experiences, many of which precede our use of language or symbols. This memory (also referred to as “procedural memory”) shapes our beliefs about how to proceed in our relational world. Unlike explicit memory, implicit memory is not fully reached through the usual psychotherapeutic dialogue but, instead, through the relational and emotional component of therapy.

Psychoanalytic theory is changing as a result of this new understanding of memory. Fonagy, a prominent analytic theorist and researcher, conducted an exhaustive review of the psychoanalytic process and outcome literature. His conclusion:
“The recovery of past experience may be helpful, but the understanding of current ways of being with the other is the key to change. For this, both self and other representations may need to alter and this can only be done effectively in the here and now.”
⁵⁴
In other words, the actual moment-to-moment experience of the client and therapist in the therapy relationship is the engine of change.

A fuller discussion of causality would take us too far afield from interpersonal learning, but I will return to the issue in chapters 5 and 6. For now, it is sufficient to emphasize that there is little doubt that intellectual understanding lubricates the machinery of change. It is important that insight—“sighting in”—occur,
but in its generic, not its genetic, sense
. And psychotherapists need to disengage the concept of “profound” or “significant” intellectual understanding from temporal considerations. Something that is deeply felt or has deep meaning for a client may or—as is usually the case—may not be related to the unraveling of the early genesis of behavior.

Chapter 3

GROUP COHESIVENESS

I
n this chapter I examine the properties of cohesiveness, the considerable evidence for group cohesiveness as a therapeutic factor, and the various pathways through which it 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 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. 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. 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 transaction, whereas a number of individuals, generally six to ten, work together in group therapy. It is not enough to say that a good relationship is necessary for successful group therapy—we must 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?

Over the past forty 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.
¹
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.
²

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.
³
Why? What makes for successful therapy? Although many factors are involved, a proper therapeutic relationship is a sine qua non for effective therapy outcome.
⁴
Research evidence overwhelmingly supports the conclusion that successful therapy—indeed even successful drug therapy—is mediated by a relationship between therapist and client that is characterized by trust, warmth, empathic understanding, and acceptance.
⁵
Although a positive therapeutic alliance is common to all effective treatments, it is not easily or routinely established. Extensive therapy research has focused on the nature of the therapeutic alliance and the specific interventions required to achieve and maintain it.
⁶

Is the quality of the relationship related to the therapist’s school of conviction? The evidence says, “No.” Experienced and effective clinicians from different schools (Freudian, nondirective, experiential, gestalt, relational, interpersonal, cognitive-behavioral, psychodrama) 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.
⁷

Note that the engaged, cohesive therapeutic relationship is necessary in
all
psychotherapies, even the so-called mechanistic approaches—cognitive, behavioral, or systems-oriented forms of psychotherapy.
⁸
A recent secondary analysis of a large comparative psychotherapy trial, the National Institute of Mental Health’s (NIMH) Treatment of Depression Collaborative Research Program, concluded that successful therapy, whether it was cognitive-behavioral therapy or interpersonal therapy, required “the presence of a positive attachment to a benevolent, supportive, and reassuring authority figure.”
⁹
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.
¹⁰

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.† At the risk of courting semantic confusion, I refer to all of these relationships in the group with the term “group cohesiveness.” Cohesiveness is a widely researched basic property of groups that has been explored in several hundred research articles. Unfortunately, there is little cohesion in the literature, which suffers from the use of different definitions, scales, subjects, and rater perspectives.
¹¹

In general, however, there is agreement 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 will defend it against internal and external threats. Such groups have a higher rate of attendance, participation, and mutual support and will defend the group standards much more than groups with less esprit de corps. Nonetheless it is difficult to formulate a precise definition. A recent comprehensive and thoughtful review concluded that cohesiveness “is like dignity: everyone can recognize it but apparently no one can describe it, much less measure it.”
¹²
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).
¹³

In this book, cohesiveness is broadly defined as the result of all the forces acting on all the members such that they remain in the group,
¹⁴
or, more simply, the attractiveness of a group for its members.
¹⁵
Members of a cohesive group feel warmth and comfort in the group and a sense of belongingness; they value the group and feel in turn that they are valued, accepted, and supported by other members.
¹⁶
†

Esprit de corps and individual cohesiveness are interdependent, and group cohesiveness is often computed simply by summing the individual members’ level of attraction to the group. Newer methods of measuring group cohesiveness from raters’ evaluations of group climate make for greater quantitative precision, but they do not negate the fact that group cohesiveness remains a function and a summation of the individual members’ sense of belongingness.
¹⁷
Keep in mind that group members are differentially attracted to the group and that cohesiveness is not fixed—once achieved, forever held—but instead fluctuates greatly during the course of the group.
¹⁸
Early cohesion and engagement is essential for the group to encompass the more challenging work that comes later in the group’s development, as more conflict and discomfort emerges.
¹⁹
Recent research has also differentiated between the individual’s sense of belonging and his or her 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.”
²⁰
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.
²¹

Before leaving the matter of definition, I 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, 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 I have discussed 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 that is important; it is not only 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 seem 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 us all. Both affiliation within the group and attachment in the individual setting address this need.
²²
Therapy groups generate a positive, self-reinforcing loop: trust–self-disclosure–empathy–acceptance–trust.
²³
The group will accept an individual, provided that the individual adheres to the group’s procedural norms, regardless of past life experiences, transgressions, or social failings. Deviant lifestyles, history of prostitution, sexual perversion, heinous criminal offenses—all of these can be accepted by the therapy group, so long as norms of nonjudgmental acceptance and inclusiveness are established early in the group.