Group Cohesiveness PDF

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Group Cohesiveness I N THIS CHAPTER WE EXAMINE THE PROPERTIES OF COHESIVENES...

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Group Cohesiveness I N THIS CHAPTER WE EXAMINE THE PROPERTIES OF COHESIVENESS, the considerable evidence for group cohesiveness as a therapeutic factor, and the various pathways through which cohesiveness exerts its therapeutic influence. What is cohesiveness and how does it influence therapeutic outcome? The short answer is that cohesiveness is the group therapy analogue to the relationship in individual therapy. First, keep in mind that a vast body of research on individual psychotherapy demonstrates that a good therapist- client relationship is essential for a positive outcome. The link between the therapeutic alliance and outcome is one of the most reliable research findings in our field.1 Is it also true that a good therapy relationship is essential in group therapy? Here again, the literature leaves little doubt that “relationship” is germane to positive outcome in group therapy.2 But relationship in group therapy is a far more complex concept than relationship in individual therapy. After all, there are only two people in the individual therapy relationship, whereas a number of individuals, generally six to ten, work together in group therapy. Hence it is insufficient to say that a good relationship is necessary for successful group therapy—we must also specify which relationship: The relationship between the client and the group therapist (or 1 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... therapists, if there are co-leaders)? Or between the group member and other members? Or perhaps even between the individual and the “group” taken as a whole? In other words, there are intrapersonal, interpersonal, and group variables to consider as well.3 Over the past sixty years, a vast number of controlled studies of psychotherapy outcome have demonstrated that the average person who receives psychotherapy is significantly improved and that the outcome from group therapy is virtually identical to that of individual therapy.4 Furthermore, there is evidence that certain clients may obtain greater benefit from group therapy than from other approaches, particularly clients dealing with stigma or social isolation and those seeking new coping skills.5 The evidence supporting the effectiveness of group psychotherapy is so compelling that it prompts us to direct our attention toward another question: What are the necessary conditions for effective psychotherapy? After all, not all psychotherapy is successful. In fact, there is evidence that treatment may be for better or for worse—although most therapists help their clients, some therapists make some clients worse.6 Why? What are the characteristics of a successful therapist? Although many factors are involved, effective therapists are empathically attuned to their clients and are able to provide an understandable, culturally resonant explanation of distress and its treatment that in turn builds the 2 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... client’s self-efficacy.7 Research evidence overwhelmingly supports the conclusion that successful therapy—indeed, even successful pharmacotherapy treatment—is mediated by a relationship between treater and client that is characterized by agreement on the goals and tasks of treatment and marked by trust, warmth, empathic understanding, and acceptance.8 Although a positive therapeutic alliance is common to all effective treatments, it is by no means easily or routinely established. Extensive therapy research has focused on the nature of the therapeutic alliance and the specific interventions required to achieve, maintain, and repair the alliance when it gets strained or frayed.9 Is the quality of the relationship related to the therapist’s theoretical orientation? The evidence says no. Effective clinicians from different schools (psychodynamic, psychoanalytic, emotion- focused, humanistic, interpersonal, cognitive- behavioral) resemble one another (and differ from nonexperts in their own school) in their conception of the ideal therapeutic relationship and in the relationship they themselves establish with their clients.10 Note that the engaged, cohesive therapeutic relationship is necessary in all effective psychotherapies, even in the so-called mechanistic approaches—cognitive, behavioral, or systems- oriented forms of psychotherapy.11 One of the first large comparative psychotherapy trials, the National Institute of Mental Health’s (NIMH) 3 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Treatment of Depression Collaborative Research Program, concluded that successful cognitive- behavioral therapy or interpersonal therapy required “the presence of a positive attachment to a benevolent, supportive, and reassuring authority figure.”12 Research has shown that the client- therapist bond and the technical elements of cognitive therapy are synergistic: a strong and positive bond in itself disconfirms depressive beliefs and facilitates the work of modifying cognitive distortions. The absence of a positive bond renders technical interventions ineffective or even harmful.13 The experience the client has of the treater is of enormous importance and is a good predictor of outcome.14 And this experience emerges in large part from the therapist’s actions and use of self.15 More and more, these core therapist relationship capacities are being recognized as key foci in training programs.16 As noted, relationship plays an equally critical role in group psychotherapy. But the group therapy analogue of the client-therapist relationship in individual therapy must be a broader concept, encompassing the individual’s relationship to the group therapist, to the other group members, and to the group as a whole. In this text we refer to all of these relationships with the term “group cohesiveness.” Cohesiveness is a widely researched basic property of groups that has been explored in several hundred research articles, reviews, and meta-analytic studies synthesizing huge data pools.17 Unfortunately, there is little 4 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... cohesion in the cohesion literature, which suffers from the lack of replication studies and the use of different definitions, scales, subjects, and rater perspectives.18 In general, however, the studies agree that groups differ from one another in the amount of “groupness” present. Those with a greater sense of solidarity, or “we-ness,” value the group more highly and have higher attendance, participation, and mutual support. Nonetheless, it is difficult to formulate a precise definition. A thoughtful review concluded that cohesiveness “is like dignity: everyone can recognize it but apparently no one can describe it, much less measure it.”19 The problem is that cohesiveness refers to overlapping dimensions. On the one hand, there is a group phenomenon—the total esprit de corps; on the other hand, there is the individual member cohesiveness (or, more strictly, the individual’s attraction to the group and to the leader).20 Furthermore, both the client’s emotional experience and the sense of task effectiveness in the group contribute to cohesion.21 In this book, we define cohesiveness as the attractiveness of a group for its members.22 Members of a cohesive group feel warmth and comfort in the group and a sense of belonging; they value the group and feel they are valued, accepted, and supported by other members.23 Esprit de corps and individual cohesiveness are interdependent, and group cohesiveness is sometimes computed simply by summing the 5 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... individual members’ level of attraction to the group. Newer, more sophisticated methods of measuring group cohesiveness, such as the Group Questionnaire (GQ) developed by Gary Burlingame and colleagues, are gaining prominence and promise a more valid and reliable assessment of group cohesion.i The more we examine cohesiveness, the more complexity we encounter. For example, we now know that each client’s view of cohesiveness is impacted by the group cohesiveness other members feel. Group cohesiveness is generally considered as a summation of the individual members’ sense of belonging, but we have also learned that group members are differentially attracted to the group—personality, interpersonal patterns, and attachment style all play a large role.24 Furthermore, while cohesiveness is not fixed but instead fluctuates greatly during the course of the group, we know that early cohesion is essential in setting the stage for the more challenging work to follow.25 Research has also differentiated between the members’ sense of belonging and their appraisal of how well the entire group is working. It is not uncommon for an individual to feel “that this group works well, but I’m not part of it.”26 It is also possible for members (for example, eating disorder clients) to value the interaction and bonding in the group yet be fundamentally opposed to the group goal. Before leaving the matter of definition, we must point out that group cohesiveness is not only a 6 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... potent therapeutic force in its own right; it is a precondition for other therapeutic factors to function optimally. When, in individual therapy, we say that it is the relationship that heals, we do not mean that love or loving acceptance is enough; we mean that an ideal therapist-client relationship creates conditions in which the necessary risk- taking, self-disclosure, catharsis, and intrapersonal and interpersonal exploration may unfold. It is the same for group therapy: Cohesiveness is necessary for other group therapeutic factors to operate. THE IMPORTANCE OF GROUP COHESIVENESS Although we discuss the therapeutic factors separately, they are, to a great degree, interdependent. Catharsis and universality, for example, are not complete processes. It is not the sheer process of ventilation, or the discovery that others have problems similar to one’s own, and the ensuing disconfirmation of one’s wretched uniqueness, that are important: it is the affective sharing of one’s inner world and then the acceptance by others that seems of paramount importance. To be accepted by others challenges the client’s belief that he or she is basically repugnant, unacceptable, or unlovable. The need for belonging is innate in all of us. Both affiliation within the group and attachment in the individual setting address this need.27 Therapy groups generate a positive, self-reinforcing loop: trust– 7 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... self-disclosure–empathy–acceptance–trust.28 If norms of nonjudgmental acceptance and inclusiveness are established early and the member adheres to the group’s procedural norms, a member will be accepted by the group regardless of past transgressions, social failings, alternative lifestyles, or substance abuse or a history of prostitution or criminal offenses. For the most part, the flawed interpersonal skills of our clients have limited their opportunities for effective sharing in either one-to-one relationships or groups. Not infrequently, the therapy group offers isolated clients their only deeply human contact. After just a few sessions, members often have a stronger sense of being at home in the group than anywhere else. Later, even years afterward, when most other recollections of the group have faded from memory, they may still remember this warm sense of belonging and acceptance. As one successful client looking back over two and a half years of group therapy put it, “the most important thing in it was just having a group there, people that I could always talk to, that wouldn’t walk out on me. There was so much caring and hating and loving in the group, and I was a part of it. I’m better now and have my own life, but it’s sad to think that the group’s not there anymore.” Furthermore, group members see that they are not just passive beneficiaries of group cohesion; they also generate that cohesion and create durable relationships—perhaps for the first time in their lives. One group member commented that he had 8 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... always attributed his aloneness to some unidentified, intractable, and repugnant character failing. It was only after he stopped missing meetings regularly because of his discouragement and sense of futility that he discovered the part he played in his aloneness: that relationships do not inevitably wither. Instead, his previous relationships had been doomed by his choice to neglect them. Some individuals internalize the group and repopulate their inner world. Years later, one client noted, “It’s as though my old group is sitting on my shoulder, watching me. I’m forever asking, What would the group say about this or that?” Often therapeutic changes persist and are consolidated because, even years later, the members don’t want to let the group down.29 Many of our clients have an impoverished history of social connection and have never felt valuable and integral to a group. For these individuals, a positive group experience may in itself be healing. Belonging in the group raises self-esteem and meets members’ dependency needs, but in ways that also foster responsibility and autonomy.30 Still, for some members, belonging can generate feelings of psychological regression: belonging can be frightening because it evokes fear of loss of self and of relinquishing personal autonomy.31 More typically, however, members of a therapy group come to mean a great deal to one another. The therapy group, at first perceived as an artificial 9 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... construct that does not matter, may come to matter very much over time as members share their innermost thoughts. We have known groups whose members support one another through times of severe depression, through manic episodes, and through divorce, abortion, suicide, and sexual abuse, or even through the here-and-now feelings of betrayal within the group when two group members violate the group norms through a sexual encounter. Even the most unlikely clients can form cohesive groups, as shown in a recent study of group therapy for marginalized intravenous drug users from the inner city with hepatitis C.32 We have seen a group actually carry one of its members to the hospital, and many groups mourning the death of a member. We have seen members of cancer support groups deliver eulogies at the funerals of other members. Relationships are often cemented by emotionally intense shared experiences. How many relationships in life are so richly layered? Benefits of Group Cohesiveness: Evidence Empirical evidence for the impact of group cohesiveness may not be as extensive or as systematic as research documenting the importance of relationship in individual psychotherapy, but is still very clear and relevant.33 Studying the effect of cohesiveness is more complex34 because it involves variables closely related to cohesion such as group climate 10 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... (the degree of engagement, avoidance, and conflict in the group),35 therapist empathy,36 and alliance (the member-therapist relationship).37 The Group Questionnaire devised by Burlingame and colleagues synthesizes all these dimensions.38 The results of the research from all these perspectives, however, point to the same conclusion: Relationship is at the heart of effective group therapy.39 Group cohesion is no less important in the era of third-party oversight than it was in the past. In fact, the contemporary group therapist has an even larger responsibility to safeguard the therapeutic relationship in the face of imposed restrictions and intrusions from bureaucratic forces.40 We now turn to a broad overview of contemporary research and literature on cohesion. It highlights many of the approaches group researchers have used to evaluate and understand group cohesion and its clinical impact. (Readers who are less interested in research methodology and more interested in its direct clinical relevance may wish to proceed directly to the summary section.) In an early study of former group psychotherapy clients, investigators found that more than half considered mutual support the primary mode of help in group therapy. Clients who perceived their group as cohesive attended more sessions, 11 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... experienced more social contact with other members, and felt that the group had been therapeutic. Improved clients were significantly more likely to have felt accepted by the other members and to mention particular individuals when queried about their group experience.41 In 1970, I (IY) reported a study in which successful group therapy clients were asked to look back over their experience and to rate, in order of effectiveness, the series of therapeutic factors I describe in this book.42 Since that time, a vast number of studies using analogous designs have generated considerable data on clients’ views of those aspects of group therapy that have been most useful. We will examine these results in depth in the next chapter; for now, it is sufficient to note that there is a strong consensus that clients regard group cohesiveness as an extremely important determinant of successful group therapy. In a six-month study of two long-term therapy groups, observers rated the process of each group session by scoring each member on five variables: acceptance, activity, sensitivity, abreaction (catharsis), and improvement.43 Weekly self-ratings were also obtained from each member. Both the research raters and group members 12 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... considered “acceptance” to be the variable most strongly related to improvement. Similar conclusions were reached in a study of forty-seven clients in twelve psychotherapy groups. Members’ self- perceived personality change correlated significantly with both their feelings of involvement in the group and their assessment of total group cohesiveness.44 My colleagues and I (IY) evaluated the one- year outcome of all forty clients who had started therapy in five outpatient groups.45 Outcome was then correlated with variables measured in the first three months of therapy. Positive outcome in therapy significantly correlated with only two predictor variables: group cohesiveness and general popularity—that is, clients who, early in the course of therapy, were most attracted to the group (high cohesiveness), and who were rated as more popular by the other group members at the sixth and twelfth weeks, had a better therapy outcome at the fiftieth week.46 The popularity finding, which in this study correlated even more positively with outcome than cohesiveness did, is, as we shall discuss shortly, relevant to group cohesiveness and sheds light on the mechanism through which group cohesiveness mediates change. 13 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... The same findings emerge in more structured groups. A study of fifty-one clients who attended ten sessions of behavioral group therapy demonstrated that “attraction to the group” correlated significantly with improved self-esteem and inversely correlated with the group dropout rate.47 The quality of intermember relationships has also been well documented as an essential ingredient in experiential groups intended to teach participants about group dynamics, such as T-groups and process groups. A rigorously designed study found a significant relationship between the quality of intermember relationships and outcome in a T-group of eleven subjects who met twice a week for a total of sixty-four hours.48 The members who entered into the most two- person mutually therapeutic relationships showed the most improvement during the course of the group.49 Furthermore, the perceived relationship with the group leader was unrelated to the extent of change. My colleagues Morton Lieberman and Matthew Miles and I (IY) conducted a study of 210 subjects in eighteen encounter groups encompassing ten ideological schools that reflected the field at the time. (These were gestalt, transactional analysis, T-groups, 14 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Synanon, personal growth, Esalen, psychoanalytic, marathon, psychodrama, and encounter tape, a group led by tape- recorded instructions.)50 Cohesiveness was assessed in several ways and reliably correlated with outcome.51 The results indicated that attraction to the group is indeed a powerful determinant of outcome. All methods of determining cohesiveness demonstrated a positive correlation between cohesiveness and outcome. A member who experienced little sense of belonging or attraction to the group, even measured early in the course of the sessions, was unlikely to benefit from the group and, in fact, was likely to have a negative outcome. Furthermore, the groups with the higher overall levels of cohesiveness had a significantly better total outcome than groups with low cohesiveness. Another large study (N = 393) of experiential training groups yielded a strong relationship between affiliativeness (a construct that overlaps considerably with cohesion) and outcome.52 Roy MacKenzie and Volker Tschuschke, studying twenty clients in long-term inpatient groups, differentiated members’ personal “emotional relatedness to the group” from their appraisal of “group work” 15 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... as a whole. The individual’s personal sense of belonging correlated with future outcome, whereas the total group work scales did not.53 Simon Budman and his colleagues developed a scale to measure cohesiveness via observations by trained raters of videotaped group sessions. They studied fifteen therapy groups and found greater reductions in psychiatric symptoms and improvement in self-esteem in the most cohesively functioning groups. Group cohesion that was evident early—within the first thirty minutes of each session— predicted better outcomes.54 A number of other studies have examined the role of the relationship between the client and the group leader in group therapy. Elsa Marziali and colleagues examined group cohesion and the client–group leader relationship in a highly structured thirty- session manualized interpersonal therapy group of clients with borderline personality disorder.55 Cohesion and member-leader relationship correlated strongly, supporting Budman’s findings, and both positively correlated with outcome.56 However, the member–group leader relationship measure was a more powerful predictor of outcome. The relationship between client and therapist 16 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... may be particularly important for clients who are vulnerable or who have volatile interpersonal relationships, because for them the therapist serves an important containing and supportive function. Anthony Joyce and colleagues explored the experience of clients treated in brief group therapy for complicated loss and bereavement. They reported that the client’s strength of alliance to the therapist predicted a better outcome and showed a higher correlation with outcome than did group cohesion. This underscores the importance of looking at the individual client’s experience and not only the group’s cohesiveness, particularly in brief groups where an early positive start is essential.57 Group therapy outcomes for social phobia were significantly better at both the end of treatment and at follow-up when clients reported higher engagement scores on the Group Climate Questionnaire developed by K. R. MacKenzie. Higher avoidance scores, in contrast, correlated with greater client distress. High conflict was also problematic and may be a sign of group trouble, rather than a necessary phase of group development that group leaders should casually accept.58 In a study of a short-term, structured, 17 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... cognitive-behavioral therapy group for social phobia, the relationship with the therapist deepened over the twelve weeks of treatment and correlated positively with outcome, but group cohesion was static and not related to outcome.59 In this study the group was a setting for therapy and not an agent of therapy. Intermember bonds were not cultivated by the study therapists, leading the authors to conclude that in highly structured groups, what might matter most is the client-therapist collaboration around the therapy tasks.60 A study of thirty-four clients with depression and social isolation treated in a twelve-session interactional problem-solving group reported that clients who described experiencing warmth and positive regard from the group leader had better therapy outcomes. The opposite also held true. Negative therapy outcomes were associated with negative client–group leader relationships. This correlative study does not address cause and effect, however: Are clients better liked by their therapist because they do well in therapy, or does being well liked promote more effort and a greater sense of well-being?61 A study on inpatient group therapy for the treatment of PTSD in active military 18 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... personnel demonstrated the significant contribution of group cohesion in effective outcomes. Group cohesion contributed a remarkable 50 percent of the variance to the outcome, and each soldier’s capacity and willingness to work with others in the group was a significant and unique predictor of outcome.62 Evaluation of outcomes in brief intensive American Group Psychotherapy Association Institute training groups were influenced by higher levels of engagement.63 Positive outcomes may well be mediated by group engagement that fosters more interpersonal communication and self-disclosure.64 Similar findings were reported in intensive experiential group training for 170 psychiatry residents who ranked group cohesion very highly in promoting openness to self-disclosure and feedback.65 There is good evidence that individual attachment style also influences the relationship between cohesion and outcome. Individuals with anxious attachment who seek security benefit from group cohesion; but group members with a dismissive and avoidant attachment style may reject the strong pull to join and may need to be supported to work in the group at a pace tailored to them.66 19 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... A study of 327 group members treated in intensive inpatient programs that centered on psychodynamic groups meeting twice weekly for twelve weeks showed a significant correlation between group cohesion and outcome but with some variations. Interpersonal style also impacts the cohesion-outcome relationship. Group cohesion was of particular importance for members who had a cold and controlling interpersonal style and were harder to engage than more submissive group members.67 Fit matters! A large body of research underscores this. The more the individual’s sense of engagement with the group aligns with the engagement level of the group as a whole, the stronger the relationship between engagement and outcome.68 Fit is also influenced by cultural norms. Western attitudes toward authority, emotional expression, self-disclosure, and individualism may contrast with other traditions.69 Studies also show that group leaders tend to overestimate the degree of cohesion in their groups and their clients’ attraction and connection to their groups. Providing group leaders with ongoing feedback using measures such as the Group Questionnaire 20 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... by the Burlingame team or the Group Session Rating Scale by Barry Duncan and Scott Miller alerts the therapist to members whose cohesion is failing or lagging. The alert provides an opportunity for early repair and is associated with improved outcomes.70 Cohesion-Outcome Relationship: Summary Let’s summarize the key findings from the research literature about the cohesion-outcome relationship. Cohesion contributes significantly and consistently to outcome. This is true for both brief and longer-term (more than twenty sessions) group therapies and consistent across settings, client age, gender, and nature of client concerns. The cohesion-outcome relationship is most evident in groups of nine or fewer members and does not hold up as well with larger groups. The correlation is most prominent in groups that are interactional, but it is still relevant even in highly structured groups. The client’s attachment and interpersonal style make a difference in the cohesion-outcome relationship. Attending to culture, gender, sexual orientation, and ethnicity enhances the therapist’s capacity to build relationships within the group. Group members deeply value the acceptance and support they receive from their therapy group. Therapy outcome is positively correlated with attraction to the group and with group popularity, a variable closely related to group support and acceptance. Individuals with positive outcomes 21 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... have had more mutually satisfying relationships with other members. Emotional connectedness, self-disclosure, and the experience of group effectiveness all contribute to group cohesiveness. The presence of cohesion in the early sessions of the group correlates with positive outcomes. It is critical that leaders quickly address problems with cohesion and be alert to each member’s personal experience of the group. Group leaders tend to overestimate the strength of connection and engagement within their groups. Cohesion requires the therapist’s diligent attention to the dynamic interplay of member and group, and regular feedback about the state of the group and its members can help focus this attention, alerting the group leader to threats to group cohesion in the interest of timely therapist responsiveness. For some clients and some groups (especially highly structured groups), the relationship with the leader may be the essential factor. A strong therapeutic relationship may not guarantee a positive outcome, but a poor therapeutic relationship will certainly not result in an effective treatment. A host of studies demonstrate that group cohesiveness results in better group attendance, greater member participation, greater influenceability of members, and many other effects. We will consider these findings in detail shortly, as we discuss the mechanism by which cohesiveness fosters therapeutic change. THE FOLLOWING CLINICAL EXAMPLE ILLUSTRATES THE 22 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... IMPORTANCE of attending to members’ different reactions to the experience of group cohesion: > Karen, a thirty-five-year-old college professor, sought group therapy to improve her interpersonal interactions with her students. Though she was a highly effective teacher and always received outstanding teaching evaluations, she resented her students, whom she experienced as intrusive and cloying. She said, “After my class I can scarcely wait to get back to my office and I waste no time putting the ‘Do Not Disturb’ sign on my door.” Her personal life was not dissimilar: she sought solitude. Though she had once been married for five years, she and her husband had never consummated their marriage. Karen resisted intimate engagement at every point. Relationships threatened her: she felt they diminished her autonomy and personhood. Upon beginning the group, she made it clear she had no interest in getting closer to others: instead her goal was to learn how to manage and tolerate people. She had little doubt that her disinterest in forming more intimate attachments emanated from her lifelong relationship with her intensely controlling and devaluing mother, who had imposed her will on every decision Karen had made in her life. It was impossible to be 23 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... close to her mother, but also impossible, Karen felt, to resist her mother’s relentless demands and attempts to control her. Karen had been in the group for several months when two new members joined the group. One of the new members, Joe, a middle-aged man, was eager to reduce his chronic feelings of isolation and alienation and immediately tried to draw close to the group members. Shortly after beginning the group he asked Karen about her personal life. Was she married? In a relationship? Karen snapped at him, “Do not ever ask me personal questions about myself. I do not want to talk about that, least of all with someone I do not know.” Taken aback, Joe looked at me (ML) imploringly. He said, “I thought we were here to get to know one another and to develop more openness. I’m confused. How does this group operate?” Another member, who had known Karen since the group started, spoke to her directly, saying, “I know you’re not comfortable sharing much of yourself, but Joe is just trying to get to know all of us here. If you are so committed to not sharing or talking with us, how do you expect to make use of the group?” I was very aware of how Karen’s defensiveness and rigidity would confound the new member and undermine the establishment of vital group norms, such as 24 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... self-disclosure and feedback. I grew even more concerned when Karen responded to the question by saying, in part, “I am not going to be one of Molyn’s trained monkeys, responding to every overture with complete submission to the request.” The “trained monkey” comment felt like a further attack on group cohesion, on group norms, and on me. Angry and protective of my group, I was sorely tempted to respond, “Yes, Karen, why are you here if you refuse to engage?” Fortunately, I caught myself. That comment would have been toxic and might well have driven Karen from the group. Instead, I said, “I am perplexed by the intensity of your reaction, Karen. It makes me wonder what is going on for you right now in the group. There is an awful lot of heat here.” She responded, “I thought I made it clear in my first session that I was here to learn to tolerate others, not to be grilled by them.” “This takes me back to our first talk, Karen, when you described your relationship with your mother who so much imposed her will on you. You made it clear to us at your first meeting that you were very sensitive to pressure and you would never again submit to anyone’s will. It seems to me that the group has respected that and never inquired into painful issues in your life but accepted you and patiently waited for 25 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... you to take the lead in sharing what you felt ready to say. Am I right?” “Yes, until today. Until Joe. I’m not in the mood to be grilled about anything by anyone here.” I turned to the new member and said, “Joe, what’s this like for you?” “Oh,” said Joe, turning to Karen. “I’m new to this. I am so sorry. I was sweating and feeling very uncomfortable and just trying to be a member here. I am so clumsy: the last thing I wanted to do was make you feel bad.” Karen looked away, dabbed her eyes, and gestured that it was time to change the subject. This was a memorable session for Karen, and later in the course of therapy she referred to it as a vital learning experience. She realized no one wanted her to be a trained monkey and that she could be in the group right now, participate at her own pace, and address her anxiety about having to expose herself instantly to new members. Maryetta, a thirty-four-year-old housewife with an emotionally impoverished background, sought therapy because of anxiety and guilt stemming from a series of extramarital affairs. Her self-esteem was exceedingly low; nothing escaped her self- excoriation: her physical appearance, her intelligence, her speech, her lack of imagination both as a mother and a wife. Although she received solace from her religious affiliation, it was a mixed blessing, because she felt too unworthy to socialize with the church folks in her community. She married a man she considered unappealing but nonetheless a good man—certainly good enough for her. Only during sex, particularly with several men at once, did she seem to come alive—to feel attractive, desirable, and able to give something of herself that seemed of value to others. However, this behavior clashed with her religious convictions and resulted in considerable anxiety and further self- derogation. Viewing the group as a social microcosm, the therapist soon noted characteristic trends in Maryetta’s group behavior. She 36 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... spoke often of the guilt issuing from her sexual behavior, and for many hours the group struggled with all the titillating ramifications of her predicament. At all other times in the group, however, she disengaged and offered nothing. She related to the group as she did to her social environment. She could belong to it, but she could not really relate to the other people: the only thing of real interest she felt she could offer was her genitals. Over time in the group she began to respond and to question others and to offer warmth, support, and feedback. She began disclosing other, nonsexual, aspects of herself and soon found herself increasingly valued by the other members. She gradually disconfirmed her belief that she had little of value to offer and soon she was forced to entertain a more realistic and positive view of herself. Gradually, an adaptive spiral ensued: she began to establish meaningful nonsexual relationships both in and out of the group, and these, in turn, further enhanced her self-esteem. Two members of a therapy group— Susan, a forty-six-year-old very proper school principal, and Jean, a twenty-one- year-old high school dropout—became locked into a vicious struggle. Susan despised Jean because of her libertine 44 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... lifestyle and what she imagined to be her sloth and promiscuity. Jean was enraged by Susan’s judgmental attitude, her sanctimoniousness, her dour sexlessness, and her closed posture to the world. Fortunately, both women were deeply committed members of the group. (Fortuitous circumstances played a part here. Jean had been a core member of the group for a year and then married and went abroad for three months. It was during Jean’s absence that Susan entered the group and became a very involved member.) Both had had considerable past difficulty in tolerating and expressing anger. Over a four-month period, they interacted heavily, at times in pitched battles. For example, Susan erupted indignantly when she found out that Jean was obtaining food stamps illegally; and Jean, learning of Susan’s virginity, ventured the opinion that she was a curiosity, a museum piece, a mid-Victorian relic. Much good group work was done because Jean and Susan, despite their conflict, never broke off communication. They learned a great deal about each other and eventually each realized the cruelty of their judgments of the other. Finally, they could both understand how much each meant to the other on both a personal and a symbolic level. Jean desperately wanted Susan’s approval; Susan deeply envied 45 of 50 12/16/2024, 1:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Jean for the freedom she had never permitted herself. In the working-through process, both fully experienced their rage, and both encountered and then accepted previously unknown parts of themselves. Ultimately, they developed an empathic understanding and then an acceptance of each other. Neither could possibly have tolerated the extreme discomfort of the conflict were it not for the strong cohesion that, despite the pain, bound them to the group.