The Theory and Practice of Group Psychotherapy (138 page)

Universality; clinical factor of; demonstration of; group members and; in medical illness groups; role in individual therapy; sexual abuse groups impacted by

Vertical disclosure; see also Metadisclosure

Vicarious experience
vs.
direct participation

Vicarious therapy.
See
Spectator therapy

Videotape playback

Videotaping of groups; in group therapy training; in research; in teaching

Viewing window

Waiting-list group

War and Peace
(Tolstoy)

Warmth

Waugh, Evelyn

“Wave effect,”

We-consciousness unity

Weight Watchers

Wellness Community

Wender, L.

West, Paula

When It Was Dark
(Thorne)

When Nietzche Wept
(Yalom)

White, R.

White, William Alanson

The Wild Duck

Will; change and; process illumination and; stifled/bound

Willful action: guiding clients to; obstacles to

Winnicott, D.

Written summaries; for ambulatory groups; confidentiality and; to convey therapist thoughts; example; functions of; group norms and; with incest survivor groups; key to understanding process; for new members; oral summaries
v.
; overview of; preparing; revivification/continuity and; in teaching; therapeutic leverage facilitated by; as therapy facilitator; as vehicle for therapist self-disclosure

Yalom, I.

“Yes. . . but” patient

a

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

b

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

c

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

d

In the following clinical examples, as elsewhere in this text, I have protected clients’ privacy by altering certain facts, such as name, occupation, and age. Also, the interaction described in the text is not reproduced verbatim but has been reconstructed from detailed clinical notes taken after each therapy meeting.

e

Dynamic
is a frequently used term in the vocabulary of psychotherapy and must be defined. It has a lay and a technical meaning. It derives from the Greek
dunasthi,
meaning “to have power or strength.” In the lay sense, then, the word evokes energy or movement (a dynamic football player or orator), but in its technical sense it refers to the idea of “forces.” In individual therapy, when we speak of a client’s “psychodynamics,” we are referring to the various forces in conflict within the client that result in certain configurations of experienced feelings and behavior. In common usage since the advent of Freud, the assumption is made that some of the forces in conflict with one another exist at different levels of awareness—indeed, some of them are entirely out of consciousness and, through the mechanism of repression, dwell in the dynamic unconsciousness. In group work, dynamics refers to inferred, invisible constructs or group properties (for example, cohesiveness, group pressure, scapegoating, and subgrouping) that affect the overall movements of the group.

f

The list of sixty factor items passed through several versions and was circulated among senior group therapists for suggestions, additions, and deletions. Some of the items are nearly identical, but it was necessary methodologically to have the same number of items representing each category. The twelve categories are altruism, group cohesiveness; universality; interpersonal learning, input; interpersonal learning, output; guidance; catharsis; identification; family reenactment; self-understanding; instillation of hope; and existential factors. They are not quite identical to those described in this book; we attempted, unsuccessfully, to divide interpersonal learning into two parts: input and output. One category, self-understanding, was included to permit examination of depression and genetic insight.

The twelve factor Q-sort utilized in this research evolved into the eleven therapeutic factors identified in Chapter 1.
Imparting information
replaces
Guidance
.
The corrective recapitulation of the primary family group replaces Family reenactment
.
Development of socializing techniques
replaces
Interpersonal learning—output
.
Interpersonal learning
replaces
Interpersonal learning—input
and
Self-understanding
. Finally,
Imitative behavior
replaces
Identification
.

The therapeutic factor was meant to be an exploratory instrument constructed
a priori
on the basis of clinical intuition (my own and that of experienced clinicians); it was never meant to be posited as a finely calibrated research instrument. But it has been used in so much subsequent research that much discussion has arisen about construct validity and test-retest reliability. By and large, test-retest reliability has been good; factor analytic studies have yielded varied results: some studies showing only fair, others good, item-to-individual scale correlation. A comprehensive factor analytic study provided fourteen item clusters that bore considerable resemblance to my original twelve therapeutic factor categories. Sullivan and Sawilowsky have demonstrated that some differences between studies may be related to inconsistencies in brief, modified forms of the questionnaire. Stone, Lewis, and Beck have constructed a brief, modified form with considerable internal consistency.

g

The twelve categories are used only for analysis and interpretation. The clients, of course, were unaware of these categories and dealt only with the sixty randomly sorted items. The rank of each category was obtained by summing the mean rank of the five items in it. Some researchers have used brief versions of a therapeutic factor questionnaire that require clients to rank-order categories. The two approaches require different tasks of the subject, and it is difficult to assess the congruence of the two approaches.

h

In considering these results, we must keep in mind that the subject’s task was a forced sort, which means that the lowest ranked items are not necessarily unimportant but are simply less important than the others.

i

Factor analysis is a statistical method that identifies the smallest number of hypothetical constructs needed to explain the greatest degree of consistency in a data set. It is a way to compress large quantities of data into a smaller but conceptually and practically consistent data groupings.

j

Recent research on the human stress response and the impact of one’s exposure to potentially traumatic events demonstrates that making sense of, and finding meaning in, one’s life experience reduces the psychological
and
physiological signs of stress.

k

The timeless and universal nature of these existential concerns is reflected in the words of the sage Hillel, 2000 years ago. Addressing his students, Hillel would say: “If I am not for myself, who will be for me? And if I am only for myself, what am I? And if not now, when?”

l

Metacommunication refers to the communication about a communication. Compare, for example: “Close the window!” “Wouldn’t you like to close the window? You must be cold.” “I’m cold, would you please close the window?” “Why is this window open?” Each of these statements contains a great deal more than a simple request or command. Each conveys a metacommunication: that is, a message about the nature of the relationship between the two interacting individuals.

m

These phenomena play havoc with outcome research strategies that focus on initial target symptoms or goals and then simply evaluate the clients’ change on these measures. It is precisely for this reason that experienced therapists are dismayed at naive contemporary mental health maintenance providers who insist on evaluating therapy every few sessions on the basis of initial goals. Using more
comprehensive
global outcome questionnaires instead, such as the Outcome Questionnaire 45, can provide meaningful feedback to therapists that keeps them aligned productively with their clients.

n

A well-conducted multisite psychotherapy trial with over 700 clients with chronic depression clearly demonstrated the importance of therapeutic approaches that help clients develop interpersonal effectiveness and reclaim personal responsibility and accountability for their interpersonal actions. A key principle of this model of psychotherapy, cognitive behavioral analysis system psychotherapy (CBASP), is that chronic depression is directly correlated with the depressed client’s loss of a sense of “cause and effect” in his or her personal world.

o

In the psychoanalytic literature, definitions of transference differ (see C. Rycroft,
Critical Dictionary of Psychoanalysis
[New York: Basic Books, 1968], and J. Sandler, G. Dave, and A. Holder, “Basic Psychoanalytic Concepts: III. Transference,”
British Journal of Psychiatry
116 [1970]: 667–72). The more rigorous definition is that transference is a state of mind of a client toward the therapist, and it is produced by displacement onto the therapist of feelings and ideas that derive from previous figures in the client’s life. Other psychoanalysts extend transference to apply not only to the analysand-analyst relationship but to other interpersonal situations. In this discussion and elsewhere in this text, I use the term “transference” liberally to refer to the irrational aspects of any relationship between two people. In its clinical manifestations, the concept is synonymous with Sullivan’s term “parataxic distortion.” As I shall discuss, there are more sources of transference than the simple transfer or displacement of feeling from a prior to a current object.

p

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.

q

At a recent psychotherapy convention, manufacturers promoted video systems that therapists could use to record every session as a safeguard against frivolous litigation.

r

A rich example of this principle is found in
Magister Ludi,
in which Herman Hesse describes an event in the lives of two renowned ancient healers (H. Hesse,
Magister Ludi
[New York: Frederick Unger, 1949], 438–67). Joseph, one of the healers, severely afflicted with feelings of worthlessness and self-doubt, sets off on a long journey across the desert to seek help from his rival, Dion. At an oasis, Joseph describes his plight to a stranger, who miraculously turns out to be Dion, whereupon Joseph accepts Dion’s invitation to go home with him in the role of patient and servant. In time, Joseph regains his former serenity and zest and ultimately becomes the friend and colleague of his master. Only after many years have passed and Dion lies on his deathbed, does he reveal that at their encounter at the oasis, he had reached a similar impasse in his life and was en route to request Joseph’s assistance.

s

This review included only studies that used random assignment to treatment situations (rather than matching or nonrandom assignment), which clearly specified the independent variables employed, and which measured dependent variables by one or more standardized instruments.

t

Meta-analysis is a statistical approach that examines a large number of scientific studies by pooling their data together into one large data set to determine findings that might be missed if one were only to examine smaller data sets.

u

Laboratory group research generally involves volunteers or, more often, university students taking courses in group therapy or counseling. The participants’ educational objective is to learn about group dynamics through firsthand experience in groups created for that purpose. Because these groups are well structured, time limited, and composed of members willing to answer study questionnaires, they lend themselves naturally to group research.

v

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 behavioral manifestations of their intimacy problems. Had the stress of the intimacy conflict not forced them to terminate, it is likely that the inherent stresses of the deviant role would have created pressures leading to termination.

w

Psychological-mindedness is the ability to identify intrapsychic factors and relate them to one’s difficulties. It appears to be a durable personality trait that does not change over time even with therapy. The Quality of Object Relations (QOR) Scale evaluates clients’ characteristic manner of relating along a continuum ranging from mature to primitive.