JtT

Jane,

I posted the youtube link of the group at the bottom. Let me know if you have any issue. I also posted 2 sources. You don’t need to use them if you don’t want. Thank you!

To prepare:

· Select one of the group therapy video demonstrations from this week’s required media Learning Resources.

The Assignment

In a 3- to 4-page paper, identify the video you selected and address the following:

· What group therapy techniques were demonstrated? How well do you believe these techniques were demonstrated?

· What evidence from the literature supports the techniques demonstrated? 

· What did you notice that the therapist did well?

· Explain something that you would have handled differently.

· What is an insight that you gained from watching the therapist handle the group therapy?

· Now imagine you are leading your own group session. How would you go about handling a difficult group member? How would you elicit participation in your group? What would you anticipate finding in the different phases of group therapy? What do you see as the benefits and challenges of group therapy?  

· Support your reasoning with at least three peer-reviewed, evidence-based sources, and explain why each of your supporting sources is considered scholarly. Attach the PDFs of your sources.

Video of group: https://www.youtube.com/watch?v=szS31h0kMI0

Chapter 2

INTERPERSONAL LEARNING

Interpersonal learning, as I define it, is a broad and complex therapeu­tic factor. It is the group therapy analogue of important therapeutic
factors in individual therapy such as insight, working through the trans­
ference, and the corrective emotional experience. But it also represents
processes unique to the group setting that unfold only as a result of spe­
cific work on the part of the therapist. To define the concept of interper­
sonal learning and to describe the mechanism whereby it mediates
therapeutic change in the individual, I first need to discuss three other
concepts:

1. The importance of interpersonal relationships
2. The corrective emotional experience
3. The group as social microcosm

THE IMPORTANCE OF
INTERPERSONAL RELATIONSHIPS

From whatever perspective we study human society-whether we scan
humanity’s broad evolutionary history or scrutinize the development of
the single individual-we are at all times obliged to consider the human
being in the matrix of his or her interpersonal relationships. There is
convincing data from the study of nonhuman primates, primitive human
cultures, and contemporary society that human beings have always lived
in groups that have been characterized by intense and persistent relarion­
ships among members and that the need to belong is a powerful, funda­
mental, and pervasive motivation.’ Interpersonal relatedness has clearly
been adaptive in an evolutionary sense: without deep, positive, reciprocal
interpersonal bonds, neither individual nor species survival would have
been possible.

19

20 INTERPERSONAL LEARNING

John Bowlby, from his studies of the early mother-child relationship,
concludes not only that attachment behavior is necessary for survival but
also that it is core, intrinsic, and genetically built in.2 If mother and infant
are separated, both experience marked anxiety concomitant with their
search for the lost object. If the separ:ltion is prolonged, the consequences
for the infant will be profound. Winnicott similarly noted, “There is no
such thing as a baby. There exists a mother-infant pair.”3 We live in a “re­
lational matrix,” according to Mitchell: “The person is comprehensible
only within this tapestry of relationships, past and present.”4

Similarly, a century ago the great American psychologist-philosopher
William James said:

We are not only gregarious animals liking to be in sight of our fellows,
but we have an innate propensity to get ourselves noticed, and noticed fa­
vorably, by our kind. No more fiendish punishment could be devised,
were such a thing physically possible, than that one should be turned
loose in society and remain absolutely unnoticed by all the members
thereof.5

Indeed, James’s speculations have been substantiated time and again by
contemporary research that documents the pain and the adverse conse­
quences of loneliness. There is, for example, persuasive evidence that the
rate for virtually every major cause of death is significantly higher for the
lonely, the single, the divorced, and the widowed. 6 Social isolation is as
much a risk factor for early mortality as obvious physical risk factors such
as smoking and obesity.7 The inverse is also true: social connection and in­
tegration have a positive impact on the course of serious illnesses such as
cancer and AIDS. 8

Recognizing the primacy of relatedness and attachment, contemporary
models of dynamic psychotherapy have evolved from a drive-based, one­
person Freudian psychology to a two-person relational psychology that
places the client’s interpersonal experience at the center of effective psy­
chotherapy.t9 Contemporary psychotherapy employs “a relational model
in which mind is envisioned as built out of interactional configurations of
self in relation to others.” 10

Building on the earlier contributions of Harry Stack Sullivan and his
interpersonal theory of psychiatry, 11 interpersonal models of psychother­
apy have become prominent. 12 Although Sullivan’s work was seminally
important, contemporary generations of therapists rarely read him. For
one thing, his language is often obscure (though there are excellent ren­
derings of his work into plain English); 13 for another, his work has so per­
vaded contemporary psychotherapeutic thought that his original writings
seem overly familiar or obvious. However, with the recent focus on inte-

https://prominent.12

https://chotherapy.t9

21 The Importance of Interpersonal Relationships

grating cognitive and interpersonal approaches in individual therapy and
in group therapy, interest in his contributions has resurged. 14 Kiesler ar­
gues in fact that the interpersonal frame is the most appropriate model
within which therapists can meaningfully synthesize cognitive, behav­
ioral, and psychodynamic approaches-it is the most comprehensive of
the integrative psychotherapies.t15

Sullivan’s formulations are exceedingly helpful for understanding the
group therapeutic process. Although a comprehensive discussion of inter­
personal theory is beyond the scope of this book, I will describe a few key
concepts here. Sullivan contends that the personality is almost entirely the
product of interaction with other significant human beings. The need to
be closely related to others is as basic as any biological need and is, in the
light of the prolonged period of helpless infancy, equally necessary to sur­
vival. The developing child, in the quest for security, tends to cultivate and
to emphasize those traits and aspects of the self that meet with approval
and to squelch or deny those that meet with disapproval. Eventually the
individual develops a concept of the self based on these perceived ap­
praisals of significant others.

The self may be said to be made up of reflected appraisals. If these were
chiefly derogatory, as in the case of an unwanted child who was never
loved, of a child who has fallen into the hands of foster parents who have
no real interest in him as a child; as I say, if the self-dynamism is made up
of experience which is chiefly derogatory, it will facilitate hostile, dis­
paraging appraisals of other people and it will entertain disparaging and
hostile appraisals of itself. 16

This process of constructing our self-regard on the basis of reflected
appraisals that we read in the eyes of important others continues, of
course, through the developmental cycle. Grunebaum and Solomon, in
their study of adolescents, have stressed that satisfying peer relationships
and self-esteem are inseparable concepts.17 The same is true for the el­
derly-we never outgrow the need for meaningful relatedness. 18

Sullivan used the term “parataxic distortions” to describe individuals’
proclivity to distort their perceptions of others. A parataxic distortion oc­
curs in an interpersonal situation when one person relates to another not
on the basis of the realistic attributes of the other but on the basis of a
personification existing chiefly in the farmer’s own fantasy. Although
parataxic distortion. is similar to the concept of transference, it differs in
two important ways. First, the scope is broader: it refers not only to an in­
dividual’s distorted view of the therapist but to all interpersonal relation­
ships (including, of course, distorted relationships among group
members). Second, the theory of origin is broader: parataxic distortion is

https://relatedness.18

https://concepts.17

https://itself.16

https://resurged.14

22 INTERPERSONAL LEARNING

constituted not only of the simple transferring onto contemporary rela­
tionships of attitudes toward real-life figures of the past but also of the
distortion of interpersonal reality in response to intrapersonal needs. I
will generally use the two terms interchangeably; despite the imputed dif­
ference in origins, transference and parataxic distortion may be consid­
ered operationally identical. Furthermore, many therapists today use the
term transference to refer to all interpersonal distortions rather than con­
fining its use to the client-therapist relationship (see chapter 7).

The transference distortions emerge from a set of deeply stored memo­
ries of early interactional experiences. 19 These memories contribute to the
construction of an internal working model that shapes the individual’s at­
tachment patterns throughout life. 20 This internal working model also
known as a schema21 consists of the individual’s beliefs about himself, the
way he makes sense of relationship cues, and the ensuing interpersonal
behavior-not only his own but the type of behavior he draws from oth­
ers.22 For instance, a young woman who grows up with depressed and
overburdened parents is likely to feel that if she is to stay connected and
attached to others, she must make no demands, suppress her indepen­
dence, and subordinate herself to the emotional needs of others.t Psy­
chotherapy may present her first opportunity to disconfirm her rigid and
limiting interpersonal road map.

Interpersonal (that is, parataxic) distortions tend to be self-perpetuat­
ing. For example, an individual with a derogatory, debased self-image
may, through selective inattention or projection, incorrectly perceive an­
other to be harsh and rejecting. Moreover, the process compounds itself
because that individual may then gradually develop mannerisms and be­
havioral traits-for example, servility, defensive antagonism, or conde­
scension-that eventually will cause others to become, in reality, harsh
and rejecting. This sequence is commonly referred to as a “self-fulfilling
prophecy”-the individual anticipates that others will respond in a cer­
tain manner and then unwittingly behaves in a manner that brings that to
pass. In other words, causality in relationships is circular and not linear.
Interpersonal research supports this thesis by demonstrating that one’s in­
terpersonal beliefs express themselves in behaviors that have a predictable
impact on others. 23

Interpersonal distortions, in Sullivan’s view, are modifiable primarily
through consensual validation-that is, through comparing one’s inter­
personal evaluations with those of others. Consensual validation is a par­
ticularly important concept in group therapy. Not infrequently a group
member alters distortions after checking out the other members’ views of
some important incident.

This brings us to Sullivan’s view of the therapeutic process. He suggests
that the proper focus of research in mental health is the study of processes

https://others.23

https://experiences.19

23 The Importance of Interpersonal Relationships

that involve or go on between people. 24 Mental disorder, or psychiatric
symptomatology in all its varied manifestations, should be translated into
interpersonal terms and treated accordingly.25 Current psychotherapies
for many disorders emphasize this principle.t “Mental disorder” also
consists of interpersonal processes that are either inadequate to the social
situation or excessively complex because the individual is relating to oth­
ers not only as they are but also in terms of distorted images based on
who they represent from the past. Maladaptive interpersonal behavior can
be further defined by its rigidity, extremism, distortion, circularity, and its
seeming inescapability. 26

Accordingly, psychiatric treatment should be directed toward the cor­
rection of interpersonal distortions, thus enabling the individual to lead a
more abundant life, to participate collaboratively with others, to obtain
interpersonal satisfactions in the context of realistic, mutually satisfying
interpersonal relationships: “One achieves mental health to the extent
that one becomes aware of one’s interpersonal relationships. ” 27 Psychi­
atric cure is the “expanding of the self to such final effect that the patient
as known to himself is much the same person as the patient behaving to
others.” 28 Although core negative beliefs about oneself do not disappear
totally with treatment, effective treatment generates a capacity for inter­
personal mastery29 such that the client can respond with a broadened,
flexible, empathetic, and more adaptive repertoire of behaviors, replacing
vicious cycles with constructive ones.

Improving interpersonal communication is the focus of a range of par­
ent and child group psychotherapy interventions that address childhood
conduct disorders and antisocial behavior. Poor communication of chil­
dren’s needs and of parental expectations generates feelings of personal
helplessness and ineffectiveness in both children and parents. These lead
to the children’s acting-out behaviors as well as to parental responses that
are often hostile, devaluing, and inadvertently inflammatory. 30 In these
groups, parents and children learn to recognize and correct maladaptive
interpersonal cycles through the use of psychoeducation, problem solv­
ing, interpersonal skills training, role-playing, and feedback.

These ideas-that therapy is broadly interpersonal, both in its goals
and in its means-are exceedingly germane to group therapy. That does
not mean that all, or even most, clients entering group therapy ask explic­
itly for help in their interpersonal relationships. Yet I have observed that
the therapeutic goals of clients often undergo a shift after a number of ses­
sions. Their initial goal, relief of suffering, is modified and eventually re­
placed by new goals, usually interpersonal in nature. For example, goals
may change from wanting relief from anxiety or depression to wanting to
learn to communicate with others, to be more trusting and honest with
others, to learn to love. In the brief group therapies, this translation of

https://inflammatory.30

https://inescapability.26

https://accordingly.25

https://people.24

24 INTERPERSONAL LEARNING

client concerns and aspirations into interpersonal ones may need to take
place earlier, at the assessment and preparation phase (see chapter 10).3 l

The goal shift from relief of suffering to change in interpersonal func­
tioning is an essential early step in the dynamic therapeutic process. It is
important in the thinking of the therapist as well. Therapists cannot, for
example, treat depression per se: depression offers no effective therapeu­
tic handhold, no rationale for examining interpersonal relationships,
which, as I hope to demonstrate, is the key to the therapeutic power of the
therapy group. It is necessary, first, to translate depression into interper­
sonal terms and then to treat the underlying interpersonal pathology.
Thus, the therapist translates depression into its interpersonal issues-for
example, passive dependency, isolation, obsequiousness, inability to ex­
press anger, hypersensitivity to separation-and then addresses those in­
terpersonal issues in therapy.

Sullivan’s statement of the overall process and goals of individual ther­
apy is deeply consistent with those of interactional group therapy. This
interpersonal and relational focus is a defining strength of group therapy.t
The emphasis on the client’s understanding of the past, of the genetic de­
velopment of those maladaptive interpersonal stances, may be less crucial
in group therapy than in the individual setting where Sullivan worked (see
chapter 6).

The theory of interpersonal relationships has become so much an inte­
gral part of the fabric of psychiatric thought that it needs no further un­
derscoring. People need people-for initial and continued survival, for
socialization, for the pursuit of satisfaction. No one-not the dying, not
the outcast, not the mighty-transcends the need for human contact.

During my many years of leading groups of individuals who all had
some advanced form of cancer, 32 I was repeatedly struck by the realization
that, in the face of death, we dread not so much nonbeing or nothingness
but the accompanying utter loneliness. Dying patients may be haunted by
interpersonal concerns-about being abandoned, for example, even
shunned, by the world of the living. One woman, for example, had
planned to give a large evening social function and learned that very
morning that her cancer, heretofore believed contained, had metastasized.
She kept the information secret and gave the party, all the while dwelling
on the horrible thought that the pain from her disease would eventually
grow so unbearable that she would become less human and, finally, unac­
ceptable to others.

The isolation of the dying is often double-edged. Patients themselves
often avoid those they most cherish, fearing that they will drag their fam­
ily and friends into the quagmire of their despair. Thus they avoid morbid
talk, develop an airy, cheery facade, and keep their fears to themselves.
Their friends and family contribute to the isolation by pulling back, by

25 The Impurtance of Interpersonal Relationships

not knowing how to speak to the dying, by not wanting to upset them or
themselves. I agree with Elisabeth Kubler-Ross that the question is not
whether but how to tell a patient openly and honestly about a fatal illness.
The patient is always informed covertly that he or she is dying by the de­
meanor, by the shrinking away, of the living. 33

Physicians often add to the isolation by keeping patients with advanced
cancer at a considerable psychological distance-perhaps to avoid their
sense of failure and futility, perhaps also to avoid dread of their own
death. They make the mistake of concluding that, after all, there is noth­
ing more they can do. Yet from the patient’s standpoint, this is the very
time when the physician is needed the most, not for technical aid but for
sheer human presence. What the patient needs is to make contact, to be
able to touch others, to voice concerns openly, to be reminded that he or
she is not only apart from but also a part of. Psychotherapeutic ap­
proaches are beginning to address these specific concerns of the termi­
nally ill-their fear of isolation and their desire to retain dignity within
their relationships.t Consider the outcasts-those individuals thought to
be so inured to rejection that their interpersonal needs have become heav­
ily calloused. The outcasts, too, have compelling social needs. I once had
an experience in a prison that provided me with a forceful reminder of the
ubiquitous nature of this human need. An untrained psychiatric techni­
cian consulted me about his therapy group, composed of twelve inmates.
The members of the group were all hardened recidivists, whose offenses
ranged from aggressive sexual violation of a minor to murder. The group,
he complained, was sluggish and persisted in focusing on extraneous, ex­
tragroup material. I agreed to observe his group and suggested that first
he obtain some sociometric information by asking each member privately
to rank-order everyone in the group for general popularity. (I had hoped
that the discussion of this task would induce the group to turn its atten­
tion upon itself.) Although we had planned to discuss these results before
the next group session, unexpected circumstances forced us to cancel our
presession consultation.

During the next group meeting, the therapist, enthusiastic bur profes­
sionally inexperienced and insensitive to interpersonal needs, announced
that he would read aloud the results of the popularity poll. Hearing this,
the group members grew agitated and fearful. They made it clear that
they did not wish to know the results. Several members spoke so vehe­
mently of the devastating possibility that they might appear at the bottom
of the list that the therapist quickly and permanently abandoned his plan
of reading the list aloud.

I suggested an alternative plan for the next meeting: each member
would indicate whose vote he cared about most and then explain his
choice. This device, also, was too threatening, and only one-third of the

https://living.33

26 INTERPERSONAL LEARNING

members ventured a choice. Nevertheless, the group shifted to an interac­
tional level and developed a degree of tension, involvement, and exhilara­
tion previously unknown. These men had received the ultimate message
of rejection from society at large: they were imprisoned, segregated, and
explicitly labeled as outcasts. To the casual observer, they seemed hard­
ened, indifferent to the subtleties of interpersonal approval and disap­
proval. Yet they cared, and cared deeply.

The need for acceptance by and interaction with others is no different
among people at the opposite pole of human fortunes-those who occupy
the ultimate realms of power, renown, or wealth. I once worked with an
enormously wealthy client for three years. The major issues revolved about
the wedge that money created between herself and others. Did anyone
value her for herself rather than her money? Was she continually being ex­
ploited by others? To whom could she complain of the burdens of a ninety­
million-dollar fortune? The secret of her wealth kept her isolated from
others. And gifts! How could she possibly give appropriate gifts without
having others feel either disappointed or awed? There is no need to belabor
the point; the loneliness of the very privileged is common knowledge.
(Loneliness is, incidentally, not irrelevant to the group therapist; in chapter
7, I will discuss the loneliness inherent in the role of group leader.)

Every group therapist has, I am sure, encountered group members who
profess indifference to or detachment from the group. They proclaim, “I
don’t care what they say or think or feel about me; they’re nothing to me;
I have no respect for the other members,” or words to that effect. My ex­
perience has been that if I can keep such clients in the group long enough,
their wishes for contact inevitably surface. They are concerned at a very
deep level about the group. One member who maintained her indifferent
posture for many months was once invited to ask the group her secret
question, the one question she would like most of all to place before the
group. To everyone’s astonishment, this seemingly aloof, detached woman
posed this question: “How can you put up with me?”

Many clients anticipate meetings with great eagerness or with anxiety;
some feel too shaken afterward to drive home or to sleep that night; many
have imaginary conversations with the group during the week. Moreover,
this engagement with other members is often long-lived; I have known
many clients who think and dream about the group members months,
even years, after the group has ended.

In short, people do not feel indifferent toward others in their group for
long. And clients do not quit the therapy group because of boredom. Be­
lieve scorn, contempt, fear, discouragement, shame, panic, hatred! Believe
any of these! But never believe indifference!

In summary, then, I have reviewed some aspects of personality devel­
opment, mature functioning, psychopathology, and psychiatric treatment

27 The Correctiue Emotional Experience

from the point of view of interpersonal theory. Many of the issues that I
have raised have a vital bearing on the therapeutic process in group ther­
apy: the concept that mental illness emanates from disturbed interper­
sonal relationships, the role of consensual validation in the modification
of interpersonal distortions, the definition of the therapeutic process as
an adaptive modification of interpersonal relationships, and the enduring
nature and potency of the human being’s social needs. Let us now turn to
the corrective emotional experience, the second of the three concepts nec­
essary to understand the therapeutic factor of interpersonal learning.

THE CORRECTIVE EMOTIONAL EXPERIENCE

In 1946, Franz Alexander, when describing the mechanism of psychoana­
lytic cure, introduced the concept of the “corrective emotional experience.”
The basic principle of treatment, he stated, “is to expose the patient, under
more favorable circumstances, to emotional situations that he could not
handle in the past. The patient, in order to be helped, must undergo a cor­
rective emotional experience suitable to repair the traumatic influence of
previous experience.” 34 Alexander insisted that intellectual insight alone is
insufficient: there must be an emotional component and systematic reality
testing as well. Patients, while affectively interacting with their therapist in
a distorted fashion because of transference, gradually must become aware
of the fact that “these reactions are not appropriate to the analyst’s reac­
tions, not only because he (the analyst) is objective, but also because he is
what he is, a person in his own right. They are not suited to the situation be­
tween patient and therapist, and they are equally unsuited to the patient’s
current interpersonal relationships in his daily life.”35

Although the idea of the corrective emotional experience was criticized
over the years because it was misconstrued as contrived, inauthentic, or
manipulative, contemporary psychotherapies view it as a cornerstone of
therapeutic effectiveness. Change both at the behavioral level and at the
deeper level of internalized images of past relationships does not occur
primarily through interpretation and insight but through meaningful here­
and-now relational experience that disconfirms the client’s pathogenic be­
liefs.36 When such discomfirmation occurs, change can be dramatic: clients
express more emotion, recall more personally relevant and formative expe­
riences, and show evidence of more boldness and a greater sense of self.37

These basic principles-the importance of the emotional experience in
therapy and the client’s discovery, through reality testing, of the inappropri­
ateness of his or her interpersonal reactions-are as crucial in group ther­
apy as in individual therapy, and possibly more so because the group setting
offers far more opportunities for the generation of corrective emotional ex­
periences. In the individual setting, the corrective emotional experience,

https://liefs.36

28 INTERPERSONAL LEARNING

valuable as it is, may be harder to come by, because the client-therapist rela­
tionship is more insular and the client is more able to dispute the spontane­
ity, scope, and authenticity of that relationship. (I believe Alexander was
aware of that, because at one point he suggested that the analyst may have
to be an actor, may have to play a role in order to create the desired emo­
tional atmosphere.) 38

No such simulation is necessary in the therapy group, which contains
many built-in tensions-tensions whose roots reach deep into primeval
layers: sibling rivalry, competition for leaders’/parents’ attention, the
struggle for dominance and status, sexual tensions, parataxic distortions,
and differences in social class, education, and values among the members.
But the evocation and expression of raw affect is not sufficient: it has to
be transformed into a corrective emotional experience. For that to occur
two conditions are required: (1) the members must experience the group
as sufficiently safe and supportive so that these tensions may be openly
expressed; (2) there must be sufficient engagement and honest feedback to
permit effective reality testing.

Over many years of clinical work, I have made it a practice to interview
clients after they have completed group therapy. I always inquire about
some critical incident, a turning point, or the most helpful single event in
therapy. Although “critical incident” is not synonymous with therapeutic
factor, the two are not unrelated, and much may be learned from an ex­
amination of single important events. My clients almost invariably cite an
incident that is highly laden emotionally and involves some other group
member, rarely the therapist.

The most common type of incident my clients report (as did clients de­
scribed by Frank and Ascher) 39 involves a sudden expression of strong dis­
like or anger toward another member. In each instance, communication
was maintained, the storm was weathered, and the client experienced a
sense of liberation from inner restraints as well as an enhanced ability to
explore more deeply his or her interpersonal relationships.

The important characteristics of such critical incidents were:

1. The client expressed strong negative affect.
2. This expression was a unique or novel experience for the client.
3. The client had always dreaded the expression of anger. Yet no cata­

strophe ensued: no one left or died; the roof did not collapse.
4. Reality testing ensued. The client realized either that the anger ex­

pressed was inappropriate in intensity or direction or that prior
avoidance of affect expression had been irrational. The client may or
may not have gained some insight, that is, learned the reasons ac­
counting either for the inappropriate affect or for the prior avoid­
ance of affect experience or expression.

29 The Corrective Emotional Experience

5. The client was enabled to interact more freely and to explore inter­
personal relationships more deeply.

Thus, when I see two group members in conflict with one another, I be­
lieve there is an excellent chance that they will be particularly important
to one another in the course of therapy. In fact, if the conflict is particu­
larly uncomfortable, I may attempt to ameliorate some of the discomfort
by expressing that hunch aloud.

The second most common type of critical incident my clients describe
also involves strong affect-but, in these instances, positive affect. For ex­
ample, a schizoid client described an incident in which he ran after and
comforted a distressed group member who had bolted from the room;
later he spoke of how profoundly he was affected by learning that he
could care for and help someone else. Others spoke of discovering their
aliveness or of feeling in touch with themselves. These incidents had in
common the following characteristics:

1. The client expressed strong positive affect-an unusual occurrence.
2. The feared catastrophe did not occur-derision, rejection, engulf­

ment, the destruction of others.
3. The client discovered a previously unknown part of the self and thus

was enabled to relate to others in a new fashion.

The third most common category of critical incident is similar to the
second. Clients recall an incident, usually involving self-disclosure, that
plunged them into greater involvement with the group. For example, a
previously withdrawn, reticent man who had missed a couple of meetings
disclosed to the group how desperately he wanted to hear the group mem­
bers say that they had missed him during his absence. Others, too, in one
fashion or another, openly asked the group for help.

To summarize, the corrective emotional experience in group therapy
has several components:

1. A strong expression of emotion, which is interpersonally directed
and constitutes a risk taken by the client.

2. A group supportive enough to permit this risk taking.
3. Reality testing, which allows the individual to examine the incident

with the aid of consensual validation from the other members.
4. A recognition of the inappropriateness of certain interpersonal feel­

ings and behavior or of the inappropriateness of avoiding certain in­
terpersonal behavior.

5. The ultimate facilitation of the individual’s ability to interact with
others more deeply and honestly.

30 INTERPERSONAL LEARNING

Therapy is an emotional and a corrective experience. This dual nature
of the therapeutic process is of elemental significance, and I will return to
it again and again in this text. We must experience something strongly;
but we must also, through our faculty of reason, understand the implica­
tions of that emotional experience.t Over time, the client’s deeply held
beliefs will change-and these changes will be reinforced if the client’s
new interpersonal behaviors evoke constructive interpersonal responses.
Even subtle interpersonal shifts can reflect a profound change and need to
be acknowledged and reinforced by the therapist and group members.

Barbara, a depressed young woman, vividly described her isolation and
alienation to the group and then turned to Alice, who had been silent.
Barbara and Alice had often sparred because R1rbarc1 would llccuse
Alice of ignoring and rejecting her. In this meeting, howeue1; Barbara
used a more gentle tone and asked Alice about the meaning of her si­
lence. Alice responded that she was listening carefully and thinking
about how much they had in common. She then added that Barbllra’s
more gentle inquiry allowed her to give voice to her thoughts rather
than defend herself against the charge of not caring, a sequence thllt
had ended badly for them both in earlier sessions. The seemingly small
but uitally important shift in Barbara’s capacity to approach Alice em­
pathically created an opportunity for repair rather than repetition.

This formulation has direct relevance to a key concept of group ther-
apy, the here-and-now, which I will discuss in depth in chapter 6. Here I
will state only chis basic premise: When the therapy group focuses on the
here-and-now, it increases in power and effectiueness.

But if the here-and-now focus (that is, a focus on what is happening in
chis room in the immediate present) is to be therapeutic, it must have t,vo
components: the group members must experience one another with as
much spontaneity and honesty as possible, and they must also reflect back
on chat experience. This reflecting back, chis self-reflectiue loop, is crucial
if an emotional experience is to be transformed into a therapeutic one. As
we shall see in the discussion of the therapist’s tasks in chapter 5, most
groups have little difficulty in entering the emotional stream of the here­
and-now; but generally it is the therapist’s job to keep directing the group
toward the self-reflective aspect of that process.

The mistaken assumption that a strong emotional experience is in itself
a sufficient force for change is seductive as well as venerable ..Modern psy­
chotherapy was conceived in chat very error: the first description of dy­
namic psychotherapy (Freud and Breuer’s 1895 Studies on Hysteria) 40

described a method of cathartic treatment based on the conviction that
hysteria is caused by a traumatic event to which the individual has never

31 The Group as Social Microcosm

fully responded emotionally. Since illness was supposed to be caused by
strangulated affect, treatment was directed toward giving a voice to the
stillborn emotion. It was not long before Freud recognized the error: emo­
tional expression, though necessary, is not a sufficient condition for
change. Freud’s discarded ideas have refused to die and have been the seed
for a continuous fringe of therapeutic ideologies. The Viennese fin-de-sie­
cle cathartic treatment still lives today in the approaches of primal
scream, bioenergetics, and the many group leaders who place an exagger­
ated emphasis on emotional catharsis.

My colleagues and I conducted an intensive investigation of the process
and outcome of many of the encounter techniques popular in the 1970s
(see chapter 16), and our findings provide much support for the dual emo­
tional-intellectual components of the psychotherapeutic process. 41

We explored, in a number of ways, the relationship between each
member’s experience in the group and his or her outcome. For example,
we asked the members after the conclusion of the group to reflect on
those aspects of the group experience they deemed most pertinent to
their change. We also asked them during the course of the group, at the
end of each meeting, to describe which event at that meeting had the
most personal significance. When we correlated the type of event with
outcome, we obtained surprising results that disconfirmed many of the
contemporary stereotypes about the prime ingredients of the successful
encounter group experience. Although emotional experiences (expres­
sion and experiencing of strong affect, self-disclosure, giving and receiv­
ing feedback) were considered extremely important, they did not
distinguish successful from unsuccessful group members. In other
words, the members who were unchanged or even had a destructive ex­
perience were as likely as successful members to value highly the emo­
tional incidents of the group.

What types of experiences did differentiate the successful from the
unsuccessful members? There was clear evidence that a cognitive com­
ponent was essential; some type of cognitive map was needed, some in­
tellectual system that framed the experience and made sense of the
emotions evoked in the group. (See chapter 16 for a full discussion of
this result.) That these findings occurred in groups led by leaders who
did not attach much importance to the intellectual component speaks
strongly for its being part of the foundation, not the facade, of the
change process. 42

THE GROUP AS SOCIAL MICROCOSM

A freely interactive group, with few structural restrictions, will, in time,
develop into a social microcosm of the participant members. Given

https://process.42

https://process.41

32 INTERPERSONAL LEARNING

enough time, group members wiH begin to be themselves: they will inter­
act with the group members as they interact with others in their social
sphere, will create in the group the same interpersonal universe they have
always inhabited. In other words, clients will, over time, automatically
and inevitably begin to display their maladaptive interpersonal behavior
in the therapy group. There is no need for them to describe or give a de­
tailed history of their pathology: they will sooner or later enact it before
the other group members’ eyes. Furthermore, their behavior serves as ac­
curate data and lacks the unwitting but inevitable blind spots of self-report.
Character pathology is often hard for the individual to report because it
is so well assimilated into the fabric of the self and outside of conscious
and explicit awareness. As a result, group therapy, with its emphasis on
feedback, is a particularly effective treatment for individuals with charac­
ter pathology. 43

This concept is of paramount importance in group therapy and is a
keystone of the entire approach to group therapy. Each member’s inter­
personal style will eventually appear in his or her transactions in the
group. Some styles result in interpersonal friction that will be manifest
early in the course of the group. Individuals who are, for example, angry,
vindictive, harshly judgmental, self-effacing, or grandly coquettish will
generate considerable interpersonal static even in the first few meetings.
Their maladaptive social patterns will quickly elicit the group’s attention.
Others may require more time in therapy before their difficulties manifest
themselves in the here-and-now of the group. This includes clients who
may be equally or more severely troubled but whose interpersonal diffi­
culties are more subtle, such as individuals who quietly exploit others,
those who achieve intimacy to a point but then, becoming frightened, dis­
engage themselves, or those who pseudo-engage, maintaining a subordi­
nate, compliant position.

The initial business of a group usually consists of dealing with the
members whose pathology is most interpersonally blatant. Some inter­
personal styles become crystal-clear from a single transaction, some from
a single group meeting, and others require many sessions of observation
to understand. The development of the ability to identify and put to ther­
apeutic advantage maladaptive interpersonal behavior as seen in the so­
cial microcosm of the small group is one of the chief tasks of a training
program for group psychotherapists. Some clinical examples may make
these principles more graphic.•·

*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.

https://pathology.43

33 The Group as Social Microcosm

The Grand Dame

Valerie, a twenty-seven-year-old musician, sought therapy with me pri­
marily because of severe marital discord of several years’ standing. She
had had considerable, unrewarding individual and hypnotic uncovering
therapy. Her husband, she reported, was an alcoholic who was reluctant
to engage her socially, intellectually, or sexually. Now the group could
have, as some groups do, investigated her marriage interminably. The
members might have taken a complete history of the courtship, of the
evolution of the discord, of her husband’s pathology, of her reasons for
marrying him, of her role in the conflict. They might have followed up
this collection of information with advice for changing the marital inter­
action or perhaps suggestions for a trial or permanent separation.

But all this historical, problem-solving activity would have been in
vain: this entire line of inquiry not only disregards the unique potential of
therapy groups but also is based on the highly questionable premise that
a client’s account of a marriage is even reasonably accurate. Groups that
function in this manner fail to help the protagonist and also suffer de­
moralization because of the ineffectiveness of a problem-solving, histori­
cal group therapy approach. Let us instead observe Valerie’s behavior as it
unfolded in the here-and-now of the group.

Valerie’s group behavior was flamboyant. First, there was her grand en­
trance, always five or ten minutes late. Bedecked in fashionable but flashy
garb, she would sweep in, sometimes throwing kisses, and immediately
begin talking, oblivious to whether another member was in the middle of
a sentence. Here was narcissism in the raw! Her worldview was so solip­
sistic that it did not take in the possibility that life could have been going
on in the group before her arrival.

After very few meetings, Valerie began to give gifts: to an obese female
member, a copy of a new diet book; to a woman with strabismus, the
name of a good ophthalmologist; to an effeminate gay client, a subscrip­
tion to Field and Stream magazine (intended, no doubt, to masculinize
him); to a twenty-four-year-old virginal male, an introduction to a
promiscuous divorced friend of hers. Gradually it became apparent that
the gifts were not duty-free. For example, she pried into the relationship
that developed between the young man and her divorced friend and in­
sisted on serving as confidante and go-between, thus exerting consider­
able control over both individuals.

Her efforts to dominate soon colored all of her interactions in the
group. I became a challenge to her, and she made various efforts to control
me. By sheer chance, a few months previously I had seen her sister in con­
sultation and referred her to a competent therapist, a clinical psychologist.
In the group Valerie congratulated me for the brilliant tactic of sending her

34 INTERPERSONAL LEARNING

sister to a psychologist; I must have divined her deep-seated aversion to
psychiatrists. Similarly, on another occasion, she responded to a comment
from me, “How perceptive you were to have noticed my hands trembling.”

The trap was set! In fact, I had neither “divined” her sister’s alleged
aversion to psychiatrists (I had simply referred her to the best therapist I
knew) nor noted Valerie’s trembling hands. If I silently accepted her un­
deserved tribute, then I would enter into a dishonest collusion with Va­
lerie; if, on the other hand, I admitted my insensitivity either to the
trembling of the hands or to the sister’s aversion, then, by acknowledging
my lack of perceptivity, I would have also been bested. She would control
me either way! In such situations, the therapist has only one real option:
to change the frame and to comment on the process-the nature and the
meaning of the entrapment. (I will have a great deal more to say about rel­
evant therapist technique in chapter 6.)

Valerie vied with me in many other ways. Intuitive and intellectually
gifted, she became the group expert on dream and fantasy interpretation.
On one occasion she saw me between group sessions to ask whether she
could use my name to take a book out of the medical library. On one
level the request was reasonable: the book (on music therapy) was related
to her profession; furthermore, having no university affiliation, she was
not permitted to use the library. However, in the context of the group
process, the request was complex in that she was testing limits; granting
her request would have signaled to the group that she had a special and
unique relationship with me. I clarified these considerations to her and
suggested further discussion in the next session. Following this perceived
rebuttal, however, she called the three male members of the group at
home and, after swearing them to secrecy, arranged to see them. She en­
gaged in sexual relations with two; the third, a gay man, was not inter­
ested in her sexual advances but she launched a formidable seduction
attempt nonetheless.

The following group meeting was horrific. Extraordinarily tense and
unproductive, it demonstrated the axiom (to be discussed later) that if
something important in the group is being actively avoided, then nothing
else of import gets talked about either. Two days later Valerie, overcome
with anxiety and guilt, asked for an individual session with me and made
a full confession. It was agreed that the whole matter should be discussed
in the next group meeting.

Valerie opened the next meeting with the words: “This is confession
day! Go ahead, Charles!” and then later, “Your turn, Louis,” deftly manip­
ulating the situation so that the confessed transgressions became the sole
responsibilities of the men in question, and not herself. Each man per­
formed as she bade him and, later in the meeting, received from her a crit­
ical evaluation of his sexual performance. A few weeks later, Valerie let her

35 The Group as Social Microcosm

estranged husband know what had happened, and he sent threatening
messages to all three men. That was the last straw! The members decided
they could no longer trust her and, in the only such instance I have known,
voted her out of the group. (She continued her therapy by joining another
group.) The saga does not end here, but perhaps I have recounted enough
to illustrate the concept of the group as social microcosm.

Let me summarize. The first step was that Valerie clearly displayed her
interpersonal pathology in the group. Her narcissism, her need for adula­
tion, her need to control, her sadistic relationship with men-the entire
tragic behavioral scroll-unrolled in the here-and-now of therapy. The
next step was reaction and feedback. The men expressed their deep hu­
miliation and anger at having to “jump through a hoop” for her and at re­
ceiving “grades” for their sexual performance. They drew away from her.
They began to reflect: “I don’t want a report card every time I have sex.
It’s controlling, like sleeping with my mother! I’m beginning to under­
stand more about your husband moving out!” and so on. The others in
the group, the female members and the therapists, shared the men’s feel­
ings about the wantonly destructive course of Valerie’s behavior-de­
structive for the group as well as for herself.

Most important of all, she had to deal with this fact: she had joined a
group of troubled individuals who were eager to help each other and
whom she grew to like and respect; yet, in the course of several weeks, she
had so poisoned her own environment that, against her conscious wishes,
she became a pariah, an outcast from a group that could have been very
helpful to her. Facing and working through these issues in her subsequent
therapy group enabled her to make substantial personal changes and to
employ much of her considerable potential constructively in her later re­
lationships and endeavors.

The Man Who Liked Robin Hood
Ron, a forty-eight-year-old attorney who was separated from his wife, en­
tered therapy because of depression, anxiety, and intense feelings of lone­
liness. His relationships with both men and women were highly
problematic. He yearned for a close male friend but had not had one since
high school. His current relationships with men assumed one of two
forms: either he and the other man related in a highly competitive, antag­
onistic fashion, which veered dangerously close to combativeness, or he
assumed an exceedingly dominant role and soon found the relationship
empty and dull.

His relationships with women had always followed a predictable se­
quence: instant attraction, a crescendo of passion, a rapid loss of interest.
His love for his wife had withered years ago and he was currently in the
midst of a painful divorce.

36 INTERPERSONAL LEARNING

Intelligent and highly articulate, Ron immediately assumed a position
of great influence in the group. He offered a continuous stream of useful
and thoughtful observations to the other members, yet kept his own pain
and his own needs well concealed. He requested nothing and accepted
nothing from me or my co-therapist. In fact, each time I set out to inter­
act with Ron, I felt myself bracing for battle. His antagonistic resistance
was so great that for months my major interaction with him consisted of
repeatedly requesting him to examine his reluctance to experience me as
someone who could offer help.

“Ron,” I suggested, giving it my best shot, “let’s understand what’s
happening. You have many areas of unhappiness in your life. I’m an ex­
perienced therapist, and you come to me for help. You come regularly, you
never miss a meeting, you pay me for my services, yet you systematically
prevent me from helping you. Either you so hide your pain that I find lit­
tle to offer you, or when I do extend some help, you reject it in one fash­
ion or another. Reason dictates that we should be allies. Shouldn’t we be
working together to help you? Tell me, how does it come about that we
are adversaries?”

But even that failed to alter our relationship. Ron seemed bemused and
skillfully and convincingly speculated that I might be identifying one of
my problems rather than his. His relationship with the other group mem­
bers was characterized by his insistence on seeing them outside the group.
He systematically arranged for some extragroup activity with each of the
members. He was a pilot and took some members flying, others sailing,
others to lavish dinners; he gave legal advice to some and became romanti­
cally involved with one of the female members; and (the final straw) he in­
vited my co-therapist, a female psychiatric resident, for a skiing weekend.

Furthermore, he refused to examine his behavior or to discuss these ex­
tragroup meetings in the group, even though the pregroup preparation
(see chapter 12) had emphasized to all the members that such unexam­
ined, undiscussed extragroup meetings generally sabotage therapy.

After one meeting when we pressured him unbearably to examine the
meaning of the extragroup invitations, especially the skiing invitation to
my co-therapist, he left the session confused and shaken. On his way
home, Ron unaccountably began to think of Robin Hood, his favorite
childhood story but something he had not thought about for decades.

Following an impulse, he went directly to the children’s section of the
nearest public library to sit in a small child’s chair and read the story one
more time. In a flash, the meaning of his behavior was illuminated! Why
had the Robin Hood legend always fascinated and delighted him? Because
Robin Hood rescued people, especially women, from tyrants!

That motif had played a powerful role in his interior life, beginning
with the Oedipal struggles in his own family. Later, in early adulthood, he

37 The Group as Social Microcosm

built up a successful law firm by first assisting in a partnership and then
enticing his boss’s employees to work for him. He had often been most at­
tracted to women who were attached to some powerful man. Even his mo­
tives for marrying were blurred: he could not distinguish between love for
his wife and desire to rescue her from a tyrannical father.

The first stage of interpersonal learning is pathology display. Ron’s
characteristic modes of relating to both men and women unfolded vividly
in the microcosm of the group. His major interpersonal motif was to
struggle with and to vanquish other men. He competed openly and, be­
cause of his intelligence and his great verbal skills, soon procured the
dominant role in the group. He then began to mobilize the other members
in the final conspiracy: the unseating of the therapist. He formed close al­
liances through extragroup meetings and by placing other members in his
debt by offering favors. Next he endeavored to capture “my women”­
first the most attractive female member and then my co-therapist.

Not only was Ron’s interpersonal pathology displayed in the group, but
so were its adverse, self-defeating consequences. His struggles with men re­
sulted in the undermining of the very reason he had come to therapy: to ob­
tain help. In fact, the competitive struggle was so powerful that any help I
extended him was experienced not as help but as defeat, a sign of weakness.

Furthermore, the microcosm of the group revealed the consequences
of his actions on the texture of his relationships with his peers. In time
the other members became aware that Ron did not really relate to them.
He only appeared to relate but, in actuality, was using them as a way of
relating to me, the powerful and feared male in the group. The others
soon felt used, felt the absence of a genuine desire in Ron to know them,
and gradually began to distance themselves from him. Only after Ron
was able to understand and to alter his intense and distorted ways of re­
lating to me was he able to turn to and relate in good faith to the other
members of the group.

“Those Damn Men”

Linda, forty-six years old and thrice divorced, entered the group because
of anxiety and severe functional gastrointestinal distress. Her major in­
terpersonal issue was her tormented, self-destructive relationship with
her current boyfriend. In fact, throughout her life she had encountered a
long series of men (father, brothers, bosses, lovers, and husbands) who
had abused her both physically and psychologically. Her account of the
abuse that she had suffered, and suffered still, at the hands of men was
harrowing.

The group could do little to help her, aside from applying balm to her
wounds and listening empathically to her accounts of continuing mistreat­
ment by her current boss and boyfriend. Then one day an unusual incident

38 INTERPERSONAL LEARNING

occurred that graphically illuminated her dynamics. She called me one
morning in great distress. She had had an extremely unsettling altercation
with her boyfriend and felt panicky and suicidal. She felt she could not
possibly wait for the next group meeting, still four days off, and pleaded
for an immediate individual session. Although it was greatly inconvenient,
I rearranged my appointments that afternoon and scheduled time to meet
her. Approximately thirty minutes before our meeting, she called and left
word with my secretary that she would not be coming in after all.

In the next group meeting, when I inquired what had happened, Linda
said that she had decided to cancel the emergency session because she was
feeling slightly better by the afternoon, and that she knew I had a rnle
that I would see a client only one time in an emergency during the whole
course of group therapy. She therefore thought it might be best to save
that option for a time when she might be even more in crisis.

I found her response bewildering. I had never made such a rule; I never
refuse to see someone in real crisis. Nor did any of the other members of
the group recall my having issued such a dictum. But Linda stuck to her
guns: she insisted that she had heard me say it, and she was dissuaded nei­
ther by my denial nor by the unanimous consensus of the other group
members. Nor did she seem concerned in any way about the inconve­
nience she had caused me. In the group discussion she grew defensive and
acnmon10us.

This incident, unfolding in the social microcosm of the group, was
highly informative and allowed us to obtain an important perspective on
Linda’s responsibility for some of her problematic relationships with
men. Up until that point, the group had to rely entirely on her portrayal
of these relationships. Linda’s accounts were convincing, and the group
had come to accept her vision of herself as victim of “all those damn men
out there.” An examination of the here-and-now incident indicated that
Linda had distorted her perceptions of at least one important man in her
life: her therapist. Moreover-and this is extremely important-she had
distorted the incident in a highly predictable fashion: she experienced me
as far more uncaring, insensitive, and authoritarian than I really was.

This was new data, and it was convincing data-and it was displayed
before the eyes of all the members. For the first time, the group began to
wonder about the accuracy of Linda’s accounts of her relationships with
men. Undoubtedly, she faithfully portrayed her feelings, but it became ap­
parent that there were perceptual distortions at work: because of her ex­
pectations of men and her highly conflicted relationships with them, she
misperceived their actions toward her.

But there was more yet to be learned from the social microcosm. An
important piece of data was the tone of the discussion: the defensiveness,
the irritation, the anger. In time I, too, became irritated by the thankless

39 The Group as Social Microcosm

inconvenience I had suffered by changing my schedule to meet with Linda.
I was further irritated by her insistence that I had proclaimed a certain in­
sensitive rule when I (and the rest of the group) knew I had not. I fell into
a reverie in which I asked myself, “What would it be like to live with Linda
all the time instead of an hour and a half a week?” If there were many
such incidents, I could imagine myself often becoming angry, exasper­
ated, and uncaring toward her. This is a particularly clear example of the
concept of the self-fulfilling prophecy described on page 22. Linda pre­
dicted that men would behave toward her in a certain way and then, un­
consciously, operated so as to bring this prediction to pass.

Men Who Could Not Feel

Allen, a thirty-year-old unmarried scientist, sought therapy for a single,
sharply delineated problem: he wanted to be able to feel sexually stimu­
lated by a woman. Intrigued by this conundrum, the group searched for
an answer. They investigated his early life, sexual habits, and fantasies. Fi­
nally, baffled, they turned to other issues in the group. As the sessions con­
tinued, Allen seemed impassive and insensitive to his own and others’
pain. On one occasion, for example, an unmarried member in great dis­
tress announced in sobs that she was pregnant and was planning to have
an abortion. During her account she also mentioned that she had had a
bad PCP trip. Allen, seemingly unmoved by her tears, persisted in posing
intellectual questions about the effects of “angel dust” and was puzzled
when the group commented on his insensitivity.

So many similar incidents occurred that the group came to expect no
emotion from him. When directly queried about his feelings, he re­
sponded as if he had been addressed in Sanskrit or Aramaic. After some
months the group formulated an answer to his oft-repeated question,
“Why can’t I have sexual feelings toward a woman?” They asked him to
consider instead why he couldn’t have any feelings toward anybody.

Changes in his behavior occurred very gradually. He learned to spot
and identify feelings by pursuing telltale autonomic signs: facial flushing,
gastric tightness, sweating palms. On one occasion a volatile woman in
the group threatened to leave the group because she was exasperated try­
ing to relate to “a psychologically deaf and dumb goddamned robot.”
Allen again remained impassive, responding only, “I’m not going to get
down to your level.”

However, the next week when he was asked about the feelings he had
taken home from the group, he said that after the meeting he had gone
home and cried like a baby. (When he left the group a year later and
looked back at the course of his therapy, he identified this incident as a
critical turning point.) Over the ensuing months he was more able to feel
and to express his feelings to the other members. His role within the

40 INTERPERSONAL LEARNING

group changed from that of tolerated mascot to that of accepted com­
peer, and his self-esteem rose in accordance with his awareness of the
members’ increased respect for him.

In another group Ed, a forty-seven-year-old engineer, sought therapy be­
cause of loneliness and his inability to find a suitable mate. Ed’s pattern
of social relationships was barren: he had never had close male friends
and had only sexualized, unsatisfying, short-lived relationships with
women who ultimately and invariably rejected him. His good social skills
and lively sense of humor resulted in his being highly valued by other
members in the early stages of the group.

As time went on and members deepened their relationships with one
another, however, Ed was left behind: soon his experience in the group re­
sembled closely his social life outside the group. The most obvious aspect
of his behavior was his limited and offensive approach to women. His
gaze was directed primarily toward their breasts or crotch; his attention
was voyeuristically directed toward their sexual lives; his comments to
them were typically simplistic and sexual in nature. Ed considered the
men in the group unwelcome competitors; for months he did not initiate
a single transaction with a man.

With so little appreciation for attachments, he, for the most part, con­
sidered people interchangeable. For example, when a member described
her obsessive fantasy that her boyfriend, who was often late, would be
killed in an automobile accident, Ed’s response was to assure her that
she was young, charming, and attractive and would have little trouble
finding another man of at least equal quality. To take another example,
Ed was always puzzled when other members appeared troubled by the
temporary absence of one of the co-therapists or, later, by the impend­
ing permanent departure of a therapist. Doubtless, he suggested, there
was, even among the students, a therapist of equal competence. (In fact,
he had seen in the hall a bosomy psychologist whom he .would particu­
larly welcome as therapist.)

He put it most succinctly when he described his MDR (minimum daily
requirement) for affection; in time it became clear to the group that the
identity of the MDR supplier was incidental to Ed-far less relevant than
its dependability.

Thus evolved the first phase of the group therapy process: the display
of interpersonal pathology. Ed did not relate to others so much a-s he used
them as equipment, as objects to supply his life needs. It was not long be­
fore he had re-created in the group his habitual-and desolate–interper­
sonal universe: he was cut off from everyone. Men reciprocated his total
indifference; women, in general, were disinclined to service his MDR, and
those women he especially craved were repulsed by his narrowly sexual-

41 The Social Microcosm: A Dynamic Interaction

ized attentions. The subsequent course of Ed’s group therapy was greatly
informed by his displaying his interpersonal pathology inside the group,
and his therapy profited enormously from focusing exhaustively on his re­
lationships with the other group members.

THE SOCIAL MICROCOSM:
A DYNAMIC INTERACTION

There is a rich and subtle dynamic interplay between the group member
and the group environment. Members shape their own microcosm, which
in turn pulls characteristic defensive behavior from each. The more spon­
taneous interaction there is, the more rapid and authentic will be the de­
velopment of the social microcosm. And that in turn increases the
likelihood that the central problematic issues of all the members will be
evoked and addressed.

For example, Nancy, a young woman with borderline personality dis­
order, entered the group because of a disabling depression, a subjective
state of disintegration, and a tendency to develop panic when left alone.
All of Nancy’s symptoms had been intensified by the threatened breakup
of the small commune in which she lived. She had long been sensitized to
the breakup of nuclear units; as a child she had felt it was her task to keep
her volatile family together, and now as an adult she nurtured the fantasy
that when she married, the various factions among her relatives would be
permanently reconciled.

How were Nancy’s dynamics evoked and worked through in the social
microcosm of the group? Slowly! It took time for these concerns to man­
ifest themselves. At first, sometimes for weeks on end, Nancy would work
comfortably on important but minor conflict areas. But then certain
events in the group would fan her major, smoldering concerns into anx­
ious conflagration. For example, the absence of a member would unsettle
her. In fact, much later, in a debriefing interview at the termination of
therapy, Nancy remarked that she often felt so stunned by the absence of
any member that she was unable to participate for the entire session.

Even tardiness troubled her and she would chide members who were
not punctual. When a member thought about leaving the group, Nancy
grew deeply concerned and could be counted on to exert maximal pres­
sure on the member to continue, regardless of the person’s best interests.
When members arranged contacts outside the group meeting, Nancy be­
came anxious at the threat to the integrity of the group. Sometimes mem­
bers felt smothered by Nancy. They drew away and expressed their
objections to her phoning them at home to check on their absence or late­
ness. Their insistence that she lighten her demands on them simply ag­
gravated Nancy’s anxiety, causing her to increase her protective efforts.

42 INTERPERSONAL LEARNING

Although she longed for comfort and safety in the group, it was, in
fact, the very appearance of these unsettling vicissitudes that made it pos­
sible for her major conflict areas to become exposed and to enter the
stream of the therapeutic work.

Not only does the small group provide a social microcosm in which the
maladaptive behavior of members is clearly displayed, but it also becomes
a laboratory in which is demonstrated, often with great clarity, the mean­
ing and the dynamics of the behavior. The therapist sees not only the be­
havior but also the events triggering it and sometimes, more important,
the anticipated and real responses of others.

The group interaction is so rich that each member’s maladaptive transac­
tion cycle is repeated many times, and members have multiple opportunities
for reflection and understanding. But if pathogenic beliefs are to be altered,
the group members must receive feedback that is clear and usable. If the
style of feedback delivery is too stressful or provocative, members may be
unable to process what the other members offer them. Sometimes the feed­
back may be premature-that is, delivered before sufficient trust is present
to soften its edge. At other times feedback can be experienced as devaluing,
coercive, or injurious. 44 How can we avoid unhelpful or harmful feedback?
Members are less likely to attack and blame one another if they can look be­
yond surface behavior and become sensitive to one another’s internal expe­
riences and underlying intentions.t Thus empathy is a critical element in the
successful group. But empathy, particularly with provocative or aggressive
clients, can be a tall order for group members and therapists alike. t

The recent contributions of the intersubjective model are relevant and
helpful here. 45 This model poses members and therapists such questions as:
“How am I implicated in what I construe as your provocativeness? What is
my part in it?” In other words, the group members and the therapist con­
tinuously affect one another. Their relationships, their meaning, patterns,
and nature, are not fixed or mandated by external influences, but jointly
constructed. A traditional view of members’ behavior sees the distortion
with which members relate events—either in their past or within the group
interaction-as solely the creation and responsibility of that member. An
intersubjective perspective acknowledges the group leader’s and other mem­
bers’ contributions to each member’s here-and-now experience-as well as
to the texture of their entire experience in the group.

Consider the client who repeatedly arrives late to the group meeting.
This is always an irritating event, and group members will inevitably ex­
press their annoyance. But the therapist should also encourage the group
to explore the meaning of that particular client’s behavior. Coming late
may mean “I don’t really care about the group,” but it may also have
many other, more complex interpersonal meanings: “Nothing happens

https://injurious.44

43 The Social Microcosm: A Dynamic Interaction

without me, so why should I rush?” or “I bet no one will even notice my
absence-they don’t seem to notice me while I’m there,” or “These rules
are meant for others, not me.”

Both the underlying meaning of the individual’s behavior and the im­
pact of that behavior on others need to be revealed and processed if the
members are to arrive at an empathic understanding of one another. Em­
pathic capacity is a key component of emotional intelligence46 and facili­
tates transfer of learning from the therapy group to the client’s larger
world. Without a sense of the internal world of others, relationships are
confusing, frustrating, and repetitive as we mindlessly enlist others as
players with predetermined roles in our own stories, without regard to
their actual motivations and aspirations.

Leonard, for example, entered the group with a major problem of pro­
crastination. In Leonard’s view, procrastination was not only a problem
but also an explanation. It explained his failures, both professionally and
socially; it explained his discouragement, depression, and alcoholism.
And yet it was an explanation that obscured meaningful insight and more
accurate explanations.

In the group we became well acquainted and often irritated or frus­
trated with Leonard’s procrastination. It served as his supreme mode of
resistance to therapy when all other resistance had failed. When members
worked hard with Leonard, and when it appeared that part of his neurotic
character was about to be uprooted, he found ways to delay the group
work. “I don’t want to be upset by the group today,” he would say, or “This
new job is make or break for me”; “I’m just hanging on by my finger­
nails”; “Give me a break-don’t rock the boat”; “I’d been sober for three
months until the last meeting caused me to stop at the bar on my way
home.” The variations were many, but the theme was consistent.

One day Leonard announced a major development, one for which he
had long labored: he had quit his job and obtained a position as a teacher.
Only a single step remained: getting a teaching certificate, a matter of fill­
ing out an application requiring approximately two hours’ labor.

Only two hours and yet he could not do it! He delayed until the allowed
time had practically expired and, with only one day remaining, informed
the group about the deadline and lamented the cruelty of his personal
demon, procrastination. Everyone in the group, including the therapists,
experienced a strong desire to sit Leonard down, possibly even in one’s
lap, place a pen between his fingers, and guide his hand along the appli­
cation form. One client, the most mothering member of the group, did
exactly that: she took him home, fed him, and schoolmarmed him
through the application form.

As we began to review what had happened, we could now see his pro­
crastination for what it was: a plaintive, anachronistic plea for a lost

44 INTERPERSONAL LEARNING

mother. Many things then fell into place, including the dynamics behind
Leonard’s depressions (which were also desperate pleas for love), alco­
holism, and compulsive overeating.

The idea of the social microcosm is, I believe, sufficiently clear: if the
group is conducted such that the members can behave in an unguarded,
unselfconscious manner, they will, most vividly, re-create and display
their pathology in the group. Thus in this living drama of the group meet­
ing, the trained observer has a unique opportunity to understand the dy­
namics of each client’s behavior.

RECOGNITION OF BEHAVIORAL PATTERNS
IN THE SOCIAL MICROCOSM

If therapists are to turn the social microcosm to therapeutic use, they
must first learn to identify the group members’ recurrent maladaptive in­
terpersonal patterns. In the incident involving Leonard, the therapist’s
vital clue was the emotional response of members and leaders to
Leonard’s behavior. These emotional responses are valid and indispens­
able data: they should not be overlooked or underestimated. The therapist
or other group members may feel angry toward a member, or exploited,
or sucked dry, or steamrollered, or intimidated, or bored, or tearful, or
any of the infinite number of ways one person can feel toward another.

These feelings represent data-a bit of the truth about the other per­
son-and should be taken seriously by the therapist. If the feelings
elicited in others are highly discordant with the feelings that the client
would like to engender in others, or if the feelings aroused are desired, yet
inhibit growth (as in the case of Leonard), then therein lies a crucial part
of the client’s problem. Of course there are many complications inherent
in this thesis. Some critics might say that a strong emotional response is
often due to pathology not of the subject but of the respondent. If, for ex­
ample, a self-confident, assertive man evokes strong feelings of fear, in­
tense envy, or bitter resentment in another man, we can hardly conclude
that the response is reflective of the farmer’s pathology. There is a distinct
advantage in the therapy group format: because the group contains multi­
ple observers, it is easier to differentiate idiosyncratic and highly subjec­
tive responses from more objective ones.

The emotional response of any single member is not sufficient; thera­
pists need confirmatory evidence. They look for repetitive patterns over
time and for multiple responses-that is, the reactions of several other
members (referred to as consensual validation) to the individual. Ulti­
mately therapists rely on the most valuable evidence of all: their own
emotional responses. Therapists must be able to attend to their own reac-

45 Recognition of Behavioral Patterns in the Social Microcosm

tions to the client, an essential skill in all relational models. If, as Kiesler
states, we are “hooked” by the interpersonal behavior of a member, our
own reactions are our best interpersonal information about the client’s
impact on others. 47

Therapeutic value follows, however, only if we are able to get “un­
hooked”-that is, to resist engaging in the usual behavior the client elicits
from others, which only reinforces the usual interpersonal cycles. This
process of retaining or regaining our objectivity provides us with mean­
ingful feedback about the interpersonal transaction. From this perspec­
tive, the thoughts, fantasies, and actual behavior elicited in the therapist
by each group member should be treated as gold. Our reactions are in­
valuable data, not failings. It is impossible not to get hooked by our
clients, except by staying so far removed from the client’s experience that
we are untouched by it-an impersonal distance that reduces our thera­
peutic effectiveness.

A critic might ask, “How can we be certain that therapists’ reactions
are ‘objective’?” Co-therapy provides one answer to that question. Co­
therapists are exposed together to the same clinical situation. Comparing
their reactions permits a clearer discrimination between their own subjec­
tive responses and objective assessments of the interactions. Furthermore,
group therapists may have a calm and privileged vantage point, since, un­
like individual therapists, they witness countless compelling maladaptive
interpersonal dramas unfold without themselves being at the center of all
these interactions.

Still, therapists do have their blind spots, their own areas of interper­
sonal conflict and distortion. How can we be certain these are not cloud­
ing their observations in the course of group therapy? I will address this
issue fully in later chapters on training and on the therapist’s tasks and
techniques, but for now note only that this argument is a powerful reason
for therapists to know themselves as fully as possible. Thus it is incumbent
upon the neophyte group therapist to embark on a lifelong journey of self­
exploration, a journey that includes both individual and group therapy.

None of this is meant to imply that therapists should not take seriously
the responses and feedback of all clients, including those who are highly
disturbed. Even the most exaggerated, irrational responses contain a core
of reality. Furthermore, the disturbed client may be a valuable, accurate
source of feedback at other times: no individual is highly conflicted in
every area. And, of course, an idiosyncratic response may contain much
information about the respondent.

This final point constitutes a basic axiom for the group therapist.
Not infrequently, members of a group respond very differently to the
same stimulus. An incident may occur in the group that each of seven or

46 INTERPERSONAL LEARNING

eight members perceives, observes, and interprets differently. One com­
mon stimulus and eight different responses-how can that be? There
seems to be only one plausible explanation: there are eight different
inner worlds. Splendid! After all, the aim of therapy is to help clients
understand and alter their inner worlds. Thus, analysis of these differ­
ing responses is a royal road-a via regia-into the inner world of the
group member.

For example, consider the first illustration offered in this chapter, the
group containing Valerie, a flamboyant, controlling member. In accord
with their inner world, each of the group members responded very differ­
ently to her, ranging from obsequious acquiescence to lust and gratitude
to impotent fury or effective confrontation.

Or, again, consider certain structural aspects of the group meeting:
members have markedly different responses to sharing the group’s or the
therapist’s attention, to disclosing themselves, to asking for help or help­
ing others. Nowhere are such differences more apparent than in the trans­
ference-the members’ responses to the leader: the same therapist will be
experienced by different members as warm, cold, rejecting, accepting,
competent, or bumbling. This range of perspectives can be humbling and
even overwhelming for therapists, particularly neophytes.

THE SOCIAL MICROCOSM-IS IT REAL?

I have often heard group members challenge the veracity of the social mi­
crocosm. Members may claim that their behavior in this particular group
is atypical, not at all representative of their normal behavior. Or that this
is a group of troubled individuals who have difficulty perceiving them ac­
curately. Or even that group therapy is not real; it is an artificial, contrived
experience that distorts rather than reflects one’s real behavior. To the
neophyte therapist, these arguments may seem formidable, even persua­
sive, but they are in fact truth-distorting. In one sense, the group is artifi­
cial: members do not choose their friends from the group; they are not
central to one another; they do not live, work, or eat together; although
they relate in a personal manner, their entire relationship consists of
meetings in a professional’s office once or twice a week; and the relation­
ships are transient-the end of the relationship is built into the social con­
tract at the very beginning.

When faced with these arguments, I often think of Earl and Mar­
guerite, members in a group I led long ago. Earl had been in the group for
four months when Marguerite was introduced. They both blushed to see
the other, because, by chance, only a month earlier, they had gone on a
Sierra Club camping trip together for a night and been “intimate.” Nei-

47 Oueruiew

ther wanted to be in the group with the other. To Earl, Marguerite was a
foolish, empty girl, “a mindless piece of ass,” as he was to put it later in
the group. To Marguerite, Earl was a dull nonentity, whose penis she had
made use of as a means of retaliation against her husband.

They worked together in the group once a week for about a year. Dur­
ing that time, they came to know each other intimately in a fuller sense of
the word: they shared their deepest feelings; they weathered fierce, vicious
battles; they helped each other through suicidal depressions; and, on more
than one occasion, they wept for each other. Which was the real world
and which the artificial?

One group member stated, “For the longest time I believed the group
was a natural place for unnatural experiences. It was only later that I re­
alized the opposite-it is an unnatural place for natural experiences.” 48

One of the things that makes the therapy group real is that it eliminates
social, sexual, and status games; members go through vital life experi­
ences together, they shed reality-distorting facades and strive to be honest
with one another. How many times have I heard a group member say,
“This is the first time I have ever told this to anyone”? The group mem­
bers are not strangers. Quite the contrary: they know one another deeply
and fully. Yes, it is true that members spend only a small fraction of their
lives together. But psychological reality is not equivalent to physical real­
ity. Psychologically, group members spend infinitely more time together
than the one or two meetings a week when they physically occupy the
same office.

OVERVIEW

Let us now return to the primary task of this chapter: to define and de­
scribe the therapeutic factor of interpersonal learning. All the necessary
premises have been posited and described in this discussion of:

1. The importance of interpersonal relationships
2. The corrective emotional experience
3. The group as a social microcosm

I have discussed these components separately. Now, if we recombine
them into a logical sequence, the mechanism of interpersonal learning as
a therapeutic factor becomes evident:

I. Psychological symptomatology emanates from disturbed interpersonal
relationships. The task of psychotherapy is to help the client learn how
to develop distortion-free, gratifying interpersonal relationships.

48 INTERPERSONAL LEARNING

II. The psychotherapy group, provided its development is unhampered
by severe structural restrictions, evolves into a social microcosm, a
miniaturized representation of each member’s social universe.

III. The group members, through feedback from others, self-reflection,
and self-observation, become aware of significant aspects of their in­
terpersonal behavior: their strengths, their limitations, their inter­
personal distortions, and the maladaptive behavior that elicits
unwanted responses from other people. The client, who will often
have had a series of disastrous relationships and subsequently suf­
fered rejection, has failed to learn from these experiences because
others, sensing the person’s general insecurity and abiding by the
rules of etiquette governing normal social interaction, have not com­
municated the reasons for rejection. Therefore, and this is impor­
tant, clients have never learned to discriminate between
objectionable aspects of their behavior and a self-concept as a to­
tally unacceptable person. The therapy group, with its encourage­
ment of accurate feedback, makes such discrimination possible.

IV. In the therapy group, a regular interpersonal sequence occurs:
A. Pathology display: the member displays his or her behavior.
B. Through feedback and self-observation, clients

1. become better witnesses of their own behavior;
2. appreciate the impact of that behavior on

a. the feelings of others;
b. the opinions that others have of them;
c. the opinions they have of themselves.

V. The client who has become fully aware of this sequence also be­
comes aware of personal responsibility for it: each individual is the
author of his or her own interpersonal world.

VI. Individuals who fully accept personal responsibility for the shaping
of their interpersonal world may then begin to grapple with the
corollary of this discovery: if they created their social-relational
world, then they have the power to change it.

VII. The depth and meaningfulness of these understandings are directly
proportional to the amount of affect associated with the sequence.
The more real and the more emotional an experience, the more po­
tent is its impact; the more distant and intellectualized the experi­
ence, the less effective is the learning.

VIII. As a result of this group therapy sequence, the client gradually
changes by risking new ways of being with others. The likelihood
that change will occur is a function of
A. The client’s motivation for change and the amount of personal

discomfort and dissatisfaction with current modes of behavior;

49 Transference and Insight

B. The client’s involvement in the group-that is, how much the
client allows the group to matter;

C. The rigidity of the client’s character structure and interpersonal
style.

IX. Once change, even modest change, occurs, the client appreciates that
some feared calamity, which had hitherto prevented such behavior,
has been irrational and can be disconfirmed; the change in behavior
has not resulted in such calamities as death, destruction, abandon­
ment, derision, or engulfment.

X. The social microcosm concept is bidirectional: not only does outside
behavior become manifest in the group, but behavior learned in the
group is eventually carried over into the client’s social environment,
and alterations appear in clients’ interpersonal behavior outside the
group.

XI. Gradually an adaptive spiral is set in motion, at first inside and then
outside the group. As a client’s interpersonal distortions diminish,
his or her ability to form rewarding relationships is enhanced. Social
anxiety decreases; self-esteem rises; the need for self-concealment di­
minishes. Behavior change is an essential component of effective
group therapy, as even small changes elicit positive responses from
others, who show more approval and acceptance of the client, which
further increases self-esteem and encourages further change. 49 Even­
tually the adaptive spiral achieves such autonomy and efficacy that
professional therapy is no longer necessary.

Each of the steps of this sequence requires different and specific facili­
tation by the therapist. At various points, for example, the therapist must
offer specific feedback, encourage self-observation, clarify the concept of
responsibility, exhort the client into risk taking, disconfirm fantasized
calamitous consequences, reinforce the transfer of learning, and so on.
Each of these tasks and techniques will be fully discussed in chapters 5
and 6.

TRANSFERENCE AND INSIGHT

Before concluding the examination of interpersonal learning as a media­
tor of change, I wish to call attention to two concepts that deserve further
discussion. Transference and insight play too central a role in most for­
mulations of the therapeutic process to be passed over lightly. I rely heav­
ily on both of these concepts in my therapeutic work and do not mean to
slight them. What I have done in this chapter is to embed them both into
the factor of interpersonal learning.

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50 INTERPERSONAL LEARNING

Transference is a specific form of interpersonal perceptual distortion.
In individual psychotherapy, the recognition and the working through of
this distortion is of paramount importance. In group therapy, working
through interpersonal distortions is, as we have seen, of no less impor­
tance; however, the range and variety of distortions are considerably
greater. Working through the transference-that is, the distortion in the
relationship to the therapist-now becomes only one of a series of dis­
tortions to be examined in the therapy process.

For many clients, perhaps for the majority, it is the most important re­
lationship to work through, because the therapist is the personification of
parental images, of teachers, of authority, of established tradition, of in­
corporated values. But most clients are also conflicted in other interper­
sonal domains: for example, power, assertiveness, anger, competitiveness
with peers, intimacy, sexuality, generosity, greed, envy.

Considerable research emphasizes the importance many group mem­
bers place on working through relationships with other members rather
than with the leader. 50 To take one example, a team of researchers asked
members, in a twelve-month follow-up of a short-term crisis group, to in­
dicate the source of the help each had received. Forty-two percent felt that
the group members and not the therapist had been helpful, and 28 percent
responded that both had been helpful. Only 5 percent said that the thera­
pist alone was a major contributor to change. 51

This body of research has important implications for the technique of
the group therapist: rather than focusing exclusively on the client-therapist
relationship, therapists must facilitate the development and working­
through of interactions among members. I will have much more to say
about these issues in chapters 6 and 7.

Insight defies precise description; it is not a unitary concept. I prefer to
employ it in the general sense of “sighting inward”-a process encom­
passing clarification, explanation, and derepression. Insight occurs when
one discovers something important about oneself-about one’s behavior,
one’s motivational system, or one’s unconscious.

In the group therapy process, clients may obtain insight on at least four
different levels:

1. Clients may gain a more objective perspective on their interpersonal
presentation. They may for the first time learn how they are seen by other
people: as tense, warm, aloof, seductive, bitter, arrogant, pompous, obse­
quious, and so on.

2. Clients may gain some understanding into their more complex interac­
tional patterns of behavior. Any of a vast number of patterns may become
clear to them: for example, that they exploit others, court constant admira­
tion, seduce and then reject or withdraw, compete relentlessly, plead for love,
or relate only to the therapist or either the male or female members.

https://change.51

https://leader.50

51 Transference and Insight

3. The third level may be termed motivational insight. Clients may learn
why they do what they do to and with other people. A common form this
type of insight assumes is learning that one behaves in certain ways be­
cause of the belief that different behavior would bring about some cata­
strophe: one might be humiliated, scorned, destroyed, or abandoned.
Aloof, detached clients, for example, may understand that they shun close­
ness because of fears of being engulfed and losing themselves; competitive,
vindictive, controlling clients may understand that they are frightened of
their deep, insatiable cravings for nurturance; timid, obsequious individu­
als may dread the eruption of their repressed, destructive rage.

4. A fourth level of insight, genetic insight, attempts to help clients un­
derstand how they got to be the way they are. Through an exploration of
the impact of early family and environmental experiences, the client un­
derstands the genesis of current patterns of behavior. The theoretical
framework and the language in which the genetic explanation is couched
are, of course, largely dependent on the therapist’s school of conviction.

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 “de­
gree 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 be­
fief 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 ge­
netic insight. Nor is there a demonstrated relationship between the acqui­
sition 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 behav­
ior and character structure. 52

For one thing, we must take into account recent neurobiological re­
search 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 rec­
ollections of one’s life, and it has historically been the focus of exploration
and interpretation in the psychodynamic therapies. A second form of

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52 INTERPERSONAL LEARNING

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, in­
stead, 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, con­
ducted an exhaustive review of the psychoanalytic process and outcome
literature. His conclusion: “The recovery of past experience may be help­
ful, 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 thera­
pist in the therapy relationship is the engine of change.

A fuller discussion of causality would take us too far afield from inter­
personal 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 in­
sight-“sighting in”—occur, but in its generic, not its genetic, sense. And
psychotherapists need to disengage the concept of “profound” or “signif­
icant” intellectual understanding from temporal considerations. Some­
thing 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 gene­
sis of behavior.

Chapter 1

THE THERAPEUTIC

FACTORS

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

How does group therapy help clients? A naive question, perhaps. But if
we can answer it with some measure of precision and certainty, we will
have at our disposal a central organizing principle with which to ap­
proach the most vexing and controversial problems of psychotherapy.
Once identified, the crucial aspects of the process of change will consti­
tute a rational basis for the therapist’s selection of tactics and strategies to
shape the group experience to maximize its potency with different clients
and in different settings.

I suggest that therapeutic change is an enormously complex process
that occurs through an intricate interplay of human experiences, which I
will refer to as “therapeutic factors.” There is considerable advantage in
approaching the complex through the simple, the total phenomenon
through its basic component processes. Accordingly, I begin by describing
and discussing these elemental factors.

From my perspective, natural lines of cleavage divide the therapeutic
experience into eleven primary factors:

1. Instillation of hope
2. Universality
3. Imparting information
4. Altruism
5. The corrective recapitulation of the primary family group
6. Development of socializing techniques

2 THE THERAPEUTIC FACTORS

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

10. Catharsis
11. Existential factors

In the rest of this chapter, I discuss the first seven factors. I consider in­
terpersonal learning and group cohesiveness so important and complex
that I have treated them separately, in the next two chapters. Existential
factors are discussed in chapter 4, where they are best understood in the
context of other material presented there. Catharsis is intricately interwo­
ven with other therapeutic factors and will also be discussed in chapter 4.

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

Keeping in mind that the therapeutic factors are arbitrary constructs,
we can view them as providing a cognitive map for the student-reader.
This grouping of the therapeutic factors is not set in concrete; other clin­
icians and researchers have arrived at a different, and also arbitrary, clus­
ter of factors. 2 No explanatory system can encompass all of therapy. At
its core, the therapy process is infinitely complex, and there is no end to
the number of pathways through the experience. (I will discuss all of
these issues more fully in chapter 4.)

The inventory of therapeutic factors I propose issues from my clinical
experience, from the experience of other therapists, from the views of the
successfully treated group patient, and from relevant systematic research.
None of these sources is beyond doubt, however; neither group members
nor group leaders are entirely objective, and our research methodology is
often crude and inapplicable.

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

3 The Therapeutic Factors

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

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

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

Despite these limitations, clients’ reports are a rich and relatively un­
tapped source of information. After all, it is their experience, theirs alone,
and the farther we move from the clients’ experience, the more inferential
are our conclusions. To be sure, there are aspects of the process of change
that operate outside a client’s awareness, but it does not follow that we
should disregard what clients do say.

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

4 THE THERAPEUTIC FACTORS

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

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

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

INSTILLATION OF HOPE

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

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

https://brain.13

https://treatment.12

https://outcome.11

5 Instillation of Hope

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

Group therapy not only draws from the general ameliorative effects of
positive expectations but also benefits from a source of hope that is
unique to the group format. Therapy groups invariably contain individu­
als who are at different points along a coping-collapse continuum. Each
member thus has considerable contact with others-often individuals
with similar problems-who have improved as a result of therapy. I have
often heard clients remark at the end of their group therapy how impor­
tant it was for them to have observed the improvement of others. Re­
markably, hope can be a powerful force even in groups of individuals
combating advanced cancer who lose cherished group members to the dis­
ease. Hope is flexible–it redefines itself to fit the immediate parameters,
becoming hope for comfort, for dignity, for connection with others, or for
minimum physical discomfort.14

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

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

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

https://group.15

https://discomfort.14

6 THE THERAPEUTIC FACTORS

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

UNIVERSALITY

Many individuals enter therapy with the disquieting thought that they are
unique in their wretchedness, that they alone have certain frightening or
unacceptable problems, thoughts, impulses, and fantasies. Of course,
there is a core of truth to this notion, since most clients have had an un­
usual constellation of severe life stresses and are periodically flooded by
frightening material that has leaked from their unconscious.

To some extent this is true for all of us, but many clients, because of
their extreme social isolation, have a heightened sense of uniqueness.
Their interpersonal difficulties preclude the possibility of deep intimacy.
In everyday life they neither learn about others’ analogous feelings and ex­
periences nor avail themselves of the opportunity to confide in, and ulti­
mately to be validated and accepted by, others.

In the therapy group, especially in the early stages, the disconfirmation
of a client’s feelings of uniqueness is a powerful source of relief. After
hearing other members disclose concerns similar to their own, clients re­
port feeling more in touch with the world and describe the process as a
“welcome to the human race” experience. Simply put, the phenomenon
finds expression in the cliche “We’re all in the same boat”-or perhaps
more cynically, “Misery loves company.”

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

https://therapies.18

https://conditions.17

7 Universality

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

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

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

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

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

https://experiences.19

8 THE THERAPEUTIC FACTORS

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

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

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

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

IMPARTING INFORMATION

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

https://culture.23

https://tragedies.22

https://suicide.21

https://universality.20

9 Imparting Information

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

Didactic Instruction

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

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

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

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

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

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

https://group.29

https://today.27

https://lines.26

https://grades.25

https://disability.24

10 THE THERAPEUTIC FACTORS

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

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

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

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

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

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

https://benefits.47

https://depression.46

https://relapse.45

11 Imparting Information

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

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

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

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

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

Direct Advice

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

https://reactions.50

https://anxiety.49

https://self-exploration.48

12 THE THERAPEUTIC FACTORS

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

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

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

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

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

https://projects.52

13 Altruism

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

ALTRUISM

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

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

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

14 THE THERAPEUTIC FACTORS

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

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

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

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

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

https://community.56

15 The Corrective Recapitulation of the Primary Family Group

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

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

THE CORRECTIVE RECAPITULATION OF
THE PRIMARY FAMILY GROUP

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

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

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16 THE THERAPEUTIC FACTORS

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

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

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

DEVELOPMENT OF SOCIALIZING TECHNIQUES

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

17 Imitative Behavior

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

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

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

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

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

IMITATIVE BEHAVIOR

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

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18 THE THERAPEUTIC FACTORS

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

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

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

https://therapy.65

https://support.61