The Therapeutic Factors: An Integration PDF

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... The Therapeutic Factors An Integration T HE THERAPEUTI...

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... The Therapeutic Factors An Integration T HE THERAPEUTIC FACTORS DESCRIBED IN THE PREVIOUS chapters can help us formulate a set of effective strategies for the therapist. We know group therapy works, but we want to address more fully how it works. We want to look “under the hood” to the processes by which group therapy exerts its effects. While we believe that the compendium of therapeutic factors we have presented is comprehensive, it is not yet fully applicable clinically. That’s because, for the sake of clarity, we have considered these therapeutic factors as separate entities, whereas in fact they are intricately interdependent. We believe that group leaders are more effective when they are able to harness the interplay of these therapeutic factors. In this chapter we first consider how the therapeutic factors operate when they are viewed not separately but as part of a dynamic process. Next, we address the comparative potency of the therapeutic factors. Obviously, they are not all of equal value at all times. However, an absolute rank-ordering of therapeutic factors is not possible across all therapeutic groups. Many variables must be considered. The importance of various therapeutic factors depends on the type of group therapy practiced. Groups differ in their clinical 1 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... populations, therapeutic goals, and treatment settings—for example, whether they are eating disorder groups, panic disorder groups, substance abuse groups, medical illness groups, online groups, outpatient groups, brief therapy groups, inpatient groups, partial hospitalization groups, or peer support groups. College counseling centers may offer ten or twenty different group therapies with a variety of foci, including LGBTQ concerns, mood and anxiety management, eating disorders, substance abuse, sexual assault, dating, writing blocks, and social justice, anti-racism, and anti- oppression issues.1 Each of these groups will likely emphasize different clusters of therapeutic factors; moreover, even a single group may change over time, with some therapeutic factors taking precedence at one stage of a group and others predominating at other stages. Some factors arise naturally in groups and others emerge only through specific therapist intent and skill. Within the same group or even the same session, different clients benefit from different therapeutic factors. Group members will respond to different factors depending on their needs, their attachment models, their social skills, and their character structure.2 Each group member’s use of a therapeutic factor can impact how others in the group experience the group therapeutic factors: one member’s self-disclosure can foster a feeling of universality in another member, or generate altruism in yet another. We must also recognize that we are discussing therapeutic factors from a Western perspective on 2 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... psychotherapy: other cultures may prioritize the therapeutic factors differently. Some factors are not always independent forces but instead create conditions for change. Instillation of hope, for example, may serve largely to prevent early discouragement and to keep members in the group until other forces for change come into play. Or consider cohesiveness: for some members, the sheer experience of being an accepted, valued member of a group may in itself be the major mechanism of change. Yet for others, cohesiveness is important, because it provides the conditions of the safety and support that allow them to express emotion, request feedback, and experiment with new interpersonal behavior. Our efforts to evaluate and integrate the therapeutic factors will always remain, to some extent, conjectural. Over the past forty-five years there has been a groundswell of research on the therapeutic factors; recent reviews have cited hundreds of studies.3 In efforts to increase the clinical utility of the therapeutic factors, some researchers categorize which groupings of therapeutic factors may be of greatest importance to particular types of groups. All of these formulations are predicated upon the factors described in this chapter.4 Yet there has been limited definitive research on the comparative value of the therapeutic factors and how they interrelate; indeed, we may never attain a high degree of certainty about these comparative values. We do not speak from a position of investigative nihilism but instead argue that our data on 3 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... therapeutic factors is so highly subjective that it challenges scientific methodology. No matter how we try to improve our data collection, we are still left trying to quantify and categorize subjective dimensions that do not fit easily into an objective categorical system.5 Accepting these research limitations, we must also recognize that there is great value in understanding the client experience through the lens of these therapeutic elements. Consider the following not atypical clinical illustration, which demonstrates the difficulty of determining which factor is most therapeutic within a treatment experience: > A new member, Barbara, a thirty-six-year- old chronically depressed single woman, sobbed as she told the group that she had been laid off. Although her job had paid little and she disliked the work, she viewed the layoff as evidence that she was unacceptable and doomed to a miserable, unhappy life. Other group members offered support and reassurance, but with minimal apparent impact. Another member, Gail, who was fifty years old and herself no stranger to depression, urged Barbara to stop beating herself up, and added that it was only after a year of hard work in the group that she was able to attain a stable mood and to view negative events as disappointments rather than damning personal indictments. Barbara nodded and then told the group 4 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... that she had desperately needed to talk and had arrived early for the meeting. However, seeing no one else in the group room, she assumed not only that the group had been canceled but also that the leader had neglected to notify her. She was angry and contemplating leaving when the group members began to arrive. As she talked, she smiled knowingly, recognizing the depressive assumptions she continually made. After a short reflection, she recalled a memory of her childhood—of her anxious mother, and her family’s motto, “Disaster is always around the corner.” She recalled that at age eight she’d had a diagnostic workup for tuberculosis because of a questionable skin test. Her mother had said, “Don’t worry —I will visit you at the sanitarium.” The diagnostic workup was negative, but her mother’s echoing words still filled her with dread. Barbara then added, “I can’t tell you what it’s like for me today, in this group, to receive this kind of feedback and reassurance instead.” The session began with the members welcoming Meena back from a two-week trip to India, where she had been born. Meena replied she had a lot to share about her trip but first had to ask about Samantha, who at the last meeting she’d attended was struggling with a huge decision about changing her career and returning to university to finish her pre-med studies. Samantha raised both hands and said, “I did it—I’m going to be a doctor,” and she and Meena exchanged high fives. Meena commented, “Samantha, you give me inspiration. I admire your courage to go after what you want and need in life. And I’m going to follow your lead and today say some things I’ve never uttered to anyone before.” 19 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Meena went on to explain that she had always feared others’ judgment, and that her anticipation of shame had silenced her. “I feel like I’ve been caught between a rock and a hard place. In America I feel foreign and ‘the other’ because I am a woman of color, and when I’m in India, I feel foreign and ‘other’ because everyone views me as a westernized American woman. This tension has always caused me to avoid romantic engagement—until now. I see others like Samantha stand up for themselves and go after what they really want. I’m inspired by her.” Meena hesitated, took a deep breath, and continued, “I’m nervous about saying this because in India we were prohibited from seeing or dating men from certain castes. It would not be an issue in the West but at home it was shameful.” “Yes… and?” asked Samantha. Meena gulped and took the plunge. “I’m in love with a former classmate who loves me back,” she said. “But I’ve always rebuffed him because of what people there would say. This group has encouraged me to pay attention to my own desires and I’ve now decided to follow my heart. I know now that life is short and should not be squandered because of what I fear others think.” “Such good news. So, you’ve told him?” asked Samantha. “Not yet, I wanted first to talk about this 20 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... here in the group.” A chorus of encouragement emanated from the group. “Go for it, Meena.” “Yes, follow your heart.” “No risk, no gain.” “I love to see you taking charge of your life. Good for you.” All her fears about being criticized if she opened up to the group were disconfirmed and Meena exhaled loudly, signaling enormous relief. She said, “A huge weight has been lifted off me tonight. I just hope it’s not too late and he is still there for me.” Then another member of the group, Bella, an immigrant from Albania, talked about her multicultural experience. The cultural divergence she experienced was much less than the one Meena had experienced, but she recognized there were aspects of child rearing in her former country that were unacceptable here. It was evident that Bella introduced this subject as a way of joining with Meena and letting her see that she was not alone in negotiating cross-cultural tensions. Bella went on to say that it was time to talk about the real reason she joined the group—her brutal self-judgment. She recounted an episode with her husband three days earlier in which she misheard a comment he made to her. Her husband was not feeling well, and when she asked him to do something, he grew angry and said, “Get off my back!” She heard instead “Get out of 21 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... my life,” and immediately was flooded with self-loathing. She left her house and retreated to her old bed in her mother’s home only a few blocks away. During the group session, as she was just emerging from this episode, she resolved that it was time to take the bull by the horns and work on her catastrophic reaction to criticism. “The same kind of thing happened to me recently in group, but it involved Mark, who’s absent today, and I don’t know if I should say it.” The group therapist encouraged Bella to continue, making clear that the group ground rules were that a member could talk about anything, including something that concerned another member, even in that person’s absence, with the proviso that we would revisit the subject in that person’s presence at the next opportunity. Bella hesitantly continued: “It was that meeting when Mark criticized me for not being compassionate or supportive to him. I’ve brooded about that for weeks but kept it to myself until today. I’m beginning to understand what I need to work on: I am supersensitive, and it is crippling me in life.… I don’t know how I got to be this way, but I think it goes back to my father—he was always on my case. I can still hear him saying, “If you can’t do it right, don’t do it at all.” Another member, Rick, said, “I liked the 22 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... way you showed compassion to Meena just now. I wish you’d start to be more compassionate with yourself. And I do hope you’re giving yourself credit for bringing up Mark’s criticism of you—that was gutsy." Meena then said to Bella, “I’m still thinking about what you said about your father and the impact of what he said to you. Makes me wonder what is at the heart of getting better here in therapy. What’s most important? Knowing the roots of your difficulty, or understanding things that are impacting right now on your life?” The group members’ response was unanimous: “What matters is any knowledge that allows you to change in the present.” Rick commented further, “I’ve been in and out of therapy for many years and although understanding my early life has enriched me in some ways, it was really only in the group that I began to change how I relate to people. Insight without change in fact can make you feel worse, more hopeless and more helpless. It’s not just insight that’s important: it’s insight that leads to change.” Gordon, a chronically depressed man, shared with the group that he’d had a lot of physical pain recently and had learned that he had a hernia in his groin that would require surgery. He wanted us to know how apprehensive he was about the pending surgery and sought some support from the group, even if, in so doing, he needed to, in his words, “drop his pants" in the meeting to tell us about it. Later in that session, when I (ML) responded to an important self-disclosure made by another member of the group about a sexual encounter, I commented that Gordon’s “dropping of his pants” had encouraged others to take more risks in the meeting. In the next session, Gordon commented, “Your joking about ‘dropping my pants’ hurt 41 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... me deeply.” He said he felt that I had been teasing him and had humiliated him in front of the group. He had not been aware of experiencing that feeling in the actual moment in the session, but it had built over the days between our meetings. “I’m so sorry,” I said. “I was hoping to support your openness, but my comment had an unintentional and hurtful impact. Could we examine what that might represent?” Gordon seemingly welcomed my apology but was unable to do anything more with the exploration. His reference to feeling humiliated, however, evoked in another group member, Sally, a recollection of a story Gordon had shared with us sessions before. “I remember you describing your father’s glee in humiliating you when the extended family would get together for dinners. I remember that he would ask you to stand up at the table and answer arithmetic questions that he knew you couldn’t do.” I asked Gordon if there was any possible connection, and he became quite energized. “Yes, right on, I felt like you were embarrassing me in front of the group, like he did in front of my family.” “Gordon, please believe me, I had no such intention in mind.” “I do believe you. Thanks. Never once did my father apologize to me.” A twenty-five-year-old perennial student, 50 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Sheila, complained of depression, loneliness, purposelessness, and severe gastric distress for which no organic cause could be found. In a pregroup individual session, she lamented repeatedly, “I don’t know what’s going on!” I (IY) could not understand precisely what she meant, and since this complaint was embedded in a litany of self-accusations, I soon forgot it. However, she did not understand what was happening to her in the group, either: she could not understand why others were so uninterested in her, why she had developed a host of somatic ailments, why she entered sexually masochistic relationships, or why she so idealized the therapist. In the group, Sheila was boring and absolutely predictable. Before every utterance, she scanned the sea of faces in the group searching for clues to what others wanted and expected. She was willing to be almost anything so as to avoid offending others and possibly driving them away from her. (Of course, she did drive others away, not from anger but from boredom.) Sheila was in chronic retreat from life, and the group tried endless approaches to halt the retreat, and to find Sheila within the cocoon of compliance she had spun around herself. No progress occurred until the group stopped encouraging Sheila, stopped attempting to force her to socialize, to study, 51 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... to write papers, to pay bills, to buy clothes, to groom herself, but instead urged her to consider the blessings of failure. What was there in failure that was so seductive and so rewarding? Quite a bit, it turned out! Failing kept her young, kept her protected, kept her from deciding. Idealizing the therapist served the same purpose. Help was out there. He knew the answers. Her job in therapy was to enfeeble herself to the point where the therapist could not in all good conscience withhold his royal touch. A critical event occurred when she developed an enlarged axillary lymph node. She had a biopsy performed, and later that day came to the group still fearfully awaiting the results (which ultimately proved the enlarged node to be benign). Never before had she so closely considered her own death, and we helped Sheila plunge into the terrifying loneliness she experienced. There are two kinds of loneliness: the primordial, existential loneliness that Sheila confronted in that meeting, and social loneliness, an inability to be with others. Social loneliness is commonly and easily worked with in a group therapeutic setting. Existential loneliness is more hidden, obscured by the distractions of everyday life, and more rarely faced. Sometimes groups confuse the two and make an effort to resolve or to heal a member’s basic loneliness. But, as Sheila learned that day, it 52 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... cannot be taken away; it cannot be resolved; it can only be known and ultimately embraced as an integral part of existence. Rather quickly, then, Sheila changed. She reintegrated far-strewn bits of herself. She began to make decisions and to take over the helm of her life. She commented, “I think I know what’s going on” (I had long forgotten her initial complaint). More than anything else, she had been trying to avoid the specter of loneliness. I think she tried to elude it by staying young, by avoiding choice and decision, by perpetuating the myth that there would always be someone who would choose for her, would accompany her, would be there for her. In the last of our three sessions, I stressed our time limit and the importance of using time well, making every moment count, and reducing regrets of things unsaid. Susan, a therapist in her fifties, asked for time and then floored me and everyone in the room. “I have been waiting twelve years for this opportunity to come and participate in this demonstration group with you. I want to tell you that the last time you were here, you saved my life. Your presentation about group therapy for women with metastatic breast cancer and what you said about not leaving things unaddressed pushed me into a mammogram that I had avoided because I dreaded the prospect of being touched and 56 of 79 12/16/2024, 3:20 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... prodded in that way. I booked an appointment shortly after that session and was shocked to learn I had an aggressive form of breast cancer. I was treated for it effectively at that time and I have been cancer-free since. I believe my characteristic neglect and avoidance would have resulted in this becoming metastatic disease and killing me. I have never put myself forward for a demo group before even though I have attended dozens of these trainings. But I was not going to miss this opportunity.” I acknowledged the profound impact her disclosure had on me. I thanked her and told her that what she had shared would stay with me forever. It underscored, better than I could have possibly imagined, the theme I had hoped to demonstrate that day about using time meaningfully and not leaving things unaddressed.