Social work

Paper social work

Table of Contents

ALSO BY IRVIN D. YALOM
Title Page
Dedication
Preface
Acknowledgements

Chapter 1 – THE THERAPEUTIC FACTORS
INSTILLATION OF HOPE
UNIVERSALITY
IMPARTING INFORMATION
ALTRUISM
THE CORRECTIVE RECAPITULATION OF THE PRIMARY FAMILY GROUP
DEVELOPMENT OF SOCIALIZING TECHNIQUES
IMITATIVE BEHAVIOR

Chapter 2 – INTERPERSONAL LEARNING
THE IMPORTANCE OF INTERPERSONAL RELATIONSHIPS
THE CORRECTIVE EMOTIONAL EXPERIENCE
THE GROUP AS SOCIAL MICROCOSM
THE SOCIAL MICROCOSM: A DYNAMIC INTERACTION
RECOGNITION OF BEHAVIORAL PATTERNS IN THE SOCIAL MICROCOSM
THE SOCIAL MICROCOSM—IS IT REAL?
OVERVIEW
TRANSFERENCE AND INSIGHT

Chapter 3 – GROUP COHESIVENESS
THE IMPORTANCE OF GROUP COHESIVENESS

MECHANISM OF ACTION
SUMMARY

Chapter 4 – THE THERAPEUTIC FACTORS: AN INTEGRATION
COMPARATIVE VALUE OF THE THERAPEUTIC FACTORS: THE CLIENT’S
VIEW
COMPARATIVE VALUE OF THE THERAPEUTIC FACTORS: DIFFERENCES
BETWEEN CLIENTS’ AND …
THERAPEUTIC FACTORS: MODIFYING FORCES

Chapter 5 – THE THERAPIST: BASIC TASKS
CREATION AND MAINTENANCE OF THE GROUP
CULTURE BUILDING
HOW DOES THE LEADER SHAPE NORMS?
EXAMPLES OF THERAPEUTIC GROUP NORMS

Chapter 6 – THE THERAPIST: WORKING IN THE HERE – AND – NOW
DEFINITION OF PROCESS
PROCESS FOCUS: THE POWER SOURCE OF THE GROUP
THE THERAPIST’S TASKS IN THE HERE-AND-NOW
TECHNIQUES OF HERE-AND-NOW ACTIVATION
TECHNIQUES OF PROCESS ILLUMINATION
HELPING CLIENTS ASSUME A PROCESS ORIENTATION
HELPING CLIENTS ACCEPT PROCESS-ILLUMINATING COMMENTS
PROCESS COMMENTARY: A THEORETICAL OVERVIEW
THE USE OF THE PAST
GROUP – AS – A – WHOLE PROCESS COMMENTARY

Chapter 7 – THE THERAPIST: TRANSFERENCE AND TRANSPARENCY
TRANSFERENCE IN THE THERAPY GROUP

THE PSYCHOTHERAPIST AND TRANSPARENCY

Chapter 8 – THE SELECTION OF CLIENTS
CRITERIA FOR EXCLUSION
CRITERIA FOR INCLUSION
AN OVERVIEW OF THE SELECTION PROCEDURE
SUMMARY

Chapter 9 – THE COMPOSITION OF THERAPY GROUPS
THE PREDICTION OF GROUP BEHAVIOR
PRINCIPLES OF GROUP COMPOSITION
OVERVIEW
A FINAL CAVEAT

Chapter 10 – CREATION OF THE GROUP: PLACE, TIME, SIZE, PREPARATION
PRELIMINARY CONSIDERATIONS
DURATION AND FREQUENCY OF MEETINGS
BRIEF GROUP THERAPY
PREPARATION FOR GROUP THERAPY

Chapter 11 – IN THE BEGINNING
FORMATIVE STAGES OF THE GROUP
THE IMPACT OF CLIENTS ON GROUP DEVELOPMENT
MEMBERSHIP PROBLEMS

Chapter 12 – THE ADVANCED GROUP
SUBGROUPING
CONFLICT IN THE THERAPY GROUP
SELF-DISCLOSURE

TERMINATION

Chapter 13 – PROBLEM GROUP MEMBERS
THE MONOPOLIST
THE SILENT CLIENT
THE BORING CLIENT
THE HELP-REJECTING COMPLAINER
THE PSYCHOTIC OR BIPOLAR CLIENT
THE CHARACTEROLOGICALLY DIFFICULT CLIENT

Chapter 14 – THE THERAPIST: SPECIALIZED FORMATS AND PROCEDURAL
AIDS
CONCURRENT INDIVIDUAL AND GROUP THERAPY
COMBINING GROUP THERAPY AND TWELVE-STEP GROUPS
CO-THERAPISTS
THE LEADERLESS MEETING
DREAMS
AUDIOVISUAL TECHNOLOGY
WRITTEN SUMMARIES
GROUP THERAPY RECORD KEEPING
STRUCTURED EXERCISES

Chapter 15 – SPECIALIZED THERAPY GROUPS
MODIFICATION OF TRADITIONAL GROUP THERAPY FOR SPECIALIZED
CLINICAL SITUATIONS: …
THE ACUTE INPATIENT THERAPY GROUP
GROUPS FOR THE MEDICALLY ILL
ADAPTATION OF CBT AND IPT TO GROUP THERAPY
SELF-HELP GROUPS AND INTERNET SUPPORT GROUPS

Chapter 16 – GROUP THERAPY: ANCESTORS AND COUSINS
WHAT IS AN ENCOUNTER GROUP?
ANTECEDENTS AND EVOLUTION OF THE ENCOUNTER GROUP
GROUP THERAPY FOR NORMALS
THE EFFECTIVENESS OF THE ENCOUNTER GROUP
THE RELATIONSHIP BETWEEN THE ENCOUNTER GROUP AND THE
THERAPY GROUP

Chapter 17 – TRAINING THE GROUP THERAPIST
OBSERVATION OF EXPERIENCED CLINICIANS
SUPERVISION
A GROUP EXPERIENCE FOR TRAINEES
PERSONAL PSYCHOTHERAPY
SUMMARY
BEYOND TECHNIQUE

Appendix – Information and Guidelines for Participation in Group Therapy
Notes
Index
Copyright Page

ALSO BY IRVIN D. YALOM
Existential Psychotherapy
Every Day Gets a Little Closer: A Twice-Told Therapy
(with Ginny Elkin)
Encounter Groups: First Facts
(with Morton A. Lieberman and Matthew B. Miles)
Inpatient Group Psychotherapy
Concise Guide to Group Psychotherapy
(with Sophia Vinogradov)
Love’s Executioner
When Nietzsche Wept
Lying on the Couch
Momma and the Meaning of Life
The Gift of Therapy
The Schopenhauer Cure

ALSO BY MOLYN LESZCZ

Treating the Elderly with Psychotherapy:
The Scope for Change in Later Life
(with Joel Sadavoy)

To the memory of my mother and father, RUTH YALOM and BENJAMIN YALOM

To the memory of my mother and father, CLARA LESZCZ and SAUL LESZCZ

Preface to the Fifth Edition
For this fifth edition of The Theory and Practice of Psychotherapy I have had the good
fortune of having Molyn Leszcz as my collaborator. Dr. Leszcz, whom I first met in 1980
when he spent a yearlong fellowship in group therapy with me at Stanford University, has
been a major contributor to research and clinical innovation in group therapy. For the past
twelve years, he has directed one of the largest group therapy training programs in the
world in the Department of Psychiatry at the University of Toronto, where he is an
associate professor. His broad knowledge of contemporary group practice and his
exhaustive review of the research and clinical literature were invaluable to the preparation
of this volume. We worked diligently, like co-therapists, to make this edition a seamless
integration of new and old material. Although for stylistic integrity we opted to retain the
first-person singular in this text, behind the “I” there is always a collaborative “we.”
Our task in this new edition was to incorporate the many new changes in the field and to
jettison outmoded ideas and methods. But we had a dilemma: What if some of the changes
in the field do not represent advances but, instead, retrogression? What if marketplace
considerations demanding quicker, cheaper, more efficient methods act against the best
interests of the client? And what if “efficiency” is but a euphemism for shedding clients
from the fiscal rolls as quickly as possible? And what if these diverse market factors force
therapists to offer less than they are capable of offering their clients?
If these suppositions are true, then the requirements of this revision become far more
complex because we have a dual task: not only to present current methods and prepare
student therapists for the contemporary workplace, but also to preserve the accumulated
wisdom and techniques of our field even if some young therapists will not have immediate
opportunities to apply them.
Since group therapy was first introduced in the 1940s, it has undergone a series of
adaptations to meet the changing face of clinical practice. As new clinical syndromes,
settings, and theoretical approaches have emerged, so have corresponding variants of
group therapy. The multiplicity of forms is so evident today that it makes more sense to
speak of “group therapies” than of “group therapy.” Groups for panic disorder, groups for
acute and chronic depression, groups to prevent depression relapse, groups for eating
disorders, medical support groups for patients with cancer, HIV/AIDS, rheumatoid
arthritis, multiple sclerosis, irritable bowel syndrome, obesity, myocardial infarction,
paraplegia, diabetic blindness, renal failure, bone marrow transplant, Parkinson’s, groups
for healthy men and women who carry genetic mutations that predispose them to develop
cancer, groups for victims of sexual abuse, for the confused elderly and for their
caregivers, for clients with obsessive-compulsive disorder, first-episode schizophrenia, for
chronic schizophrenia, for adult children of alcoholics, for parents of sexually abused
children, for male batterers, for self-mutilators, for the divorced, for the bereaved, for
disturbed families, for married couples—all of these, and many more, are forms of group
therapy.
The clinical settings of group therapy are also diverse: a rapid turnover group for

chronically or acutely psychotic patients on a stark hospital ward is group therapy, and so
are groups for imprisoned sex offenders, groups for residents of a shelter for battered
women, and open-ended groups of relatively well functioning individuals with neurotic or
personality disorders meeting in the well-appointed private office of a psychotherapist.
And the technical approaches are bewilderingly different: cognitive-behavioral,
psychoeducational, interpersonal, gestalt, supportive-expressive, psychoanalytic, dynamic-
interactional, psychodrama—all of these, and many more, are used in group therapy.
This family gathering of group therapies is swollen even more by the presence of
distant cousins to therapy groups entering the room: experiential classroom training
groups (or process groups) and the numerous self-help (or mutual support) groups like
Alcoholics Anonymous and other twelve-step recovery groups, Adult Survivors of Incest,
Sex Addicts Anonymous, Parents of Murdered Children, Overeaters Anonymous, and
Recovery, Inc. Although these groups are not formal therapy groups, they are very often
therapeutic and straddle the blurred borders between personal growth, support, education,
and therapy (see chapter 16 for a detailed discussion of this topic). And we must also
consider the youngest, most rambunctious, and most unpredictable of the cousins: the
Internet support groups, offered in a rainbow of flavors.
How, then, to write a single book that addresses all these group therapies? The strategy
I chose thirty-five years ago when I wrote the first edition of this book seems sound to me
still. My first step was to separate “front” from “core” in each of the group therapies. The
front consists of the trappings, the form, the techniques, the specialized language, and the
aura surrounding each of the ideological schools; the core consists of those aspects of the
experience that are intrinsic to the therapeutic process—that is, the bare-boned
mechanisms of change.
If you disregard the “front” and consider only the actual mechanisms of effecting
change in the client, you will find that the change mechanisms are limited in number and
are remarkably similar across groups. Therapy groups with similar goals that appear
wildly different in external form may rely on identical mechanisms of change.
In the first two editions of this book, caught up in the positivistic zeitgeist surrounding
the developing psychotherapies, I referred to these mechanisms of change as “curative
factors.” Educated and humbled by the passing years, I know now that the harvest of
psychotherapy is not cure—surely, in our field, that is an illusion—but instead change or
growth. Hence, yielding to the dictates of reality, I now refer to the mechanisms of change
as “therapeutic factors” rather than “curative factors.”
The therapeutic factors constitute the central organizing principle of this book. I begin
with a detailed discussion of eleven therapeutic factors and then describe a
psychotherapeutic approach that is based on them.
But which types of groups to discuss? The array of group therapies is now so vast that it
is impossible for a text to address each type of group separately. How then to proceed? I
have chosen in this book to center my discussion around a prototypic type of group
therapy and then to offer a set of principles that will enable the therapist to modify this

fundamental group model to fit any specialized clinical situation.
The prototypical model is the intensive, heterogeneously composed outpatient
psychotherapy group, meeting for at least several months, with the ambitious goals of both
symptomatic relief and personality change. Why focus on this particular form of group
therapy when the contemporary therapy scene, driven by economic factors, is dominated
by another type of group—a homogeneous, symptom-oriented group that meets for briefer
periods and has more limited goals?
The answer is that long-term group therapy has been around for many decades and has
accumulated a vast body of knowledge from both empirical research and thoughtful
clinical observation. Earlier I alluded to contemporary therapists not often having the
clinical opportunities to do their best work; I believe that the prototypical group we
describe in this book is the setting in which therapists can offer maximum benefit to their
clients. It is an intensive, ambitious form of therapy that demands much from both client
and therapist. The therapeutic strategies and techniques required to lead such a group are
sophisticated and complex. However, once students master them and understand how to
modify them to fit specialized therapy situations, they will be in a position to fashion a
group therapy that will be effective for any clinical population in any setting. Trainees
should aspire to be creative and compassionate therapists with conceptual depth, not
laborers with little vision and less morale. Managed care emphatically views group
therapy as the treatment modality of the future. Group therapists must be as prepared as
possible for this opportunity.
Because most readers of this book are clinicians, the text is intended to have immediate
clinical relevance. I also believe, however, that it is imperative for clinicians to remain
conversant with the world of research. Even if therapists do not personally engage in
research, they must know how to evaluate the research of others. Accordingly, the text
relies heavily on relevant clinical, social, and psychological research.
While searching through library stacks during the writing of early editions of this book,
I often found myself browsing in antiquated psychiatric texts. How unsettling it is to
realize that the devotees of such therapy endeavors as hydrotherapy, rest cures, lobotomy,
and insulin coma were obviously clinicians of high intelligence, dedication, and integrity.
The same may be said of earlier generations of therapists who advocated venesection,
starvation, purgation, and trephination. Their texts are as well written, their optimism as
unbridled, and their reported results as impressive as those of contemporary practitioners.
Question: why have other health-care fields left treatment of psychological disturbance
so far behind? Answer: because they have applied the principles of the scientific method.
Without a rigorous research base, the psychotherapists of today who are enthusiastic about
current treatments are tragically similar to the hydrotherapists and lobotomists of
yesteryear. As long as we do not test basic principles and treatment outcomes with
scientific rigor, our field remains at the mercy of passing fads and fashions. Therefore,
whenever possible, the approach presented in this text is based on rigorous, relevant
research, and attention is called to areas in which further research seems especially
necessary and feasible. Some areas (for example, preparation for group therapy and the

reasons for group dropouts) have been widely and competently studied, while other areas
(for example, “working through” or countertransference) have only recently been touched
by research. Naturally, this distribution of research emphasis is reflected in the text: some
chapters may appear, to clinicians, to stress research too heavily, while other chapters may
appear, to research-minded colleagues, to lack rigor.
Let us not expect more of psychotherapy research than it can deliver. Will the findings
of psychotherapy research affect a rapid major change in therapy practice? Probably not.
Why? “Resistance” is one reason. Complex systems of therapy with adherents who have
spent many years in training and apprenticeship and cling stubbornly to tradition will
change slowly and only in the face of very substantial evidence. Furthermore, front-line
therapists faced with suffering clients obviously cannot wait for science. Also, keep in
mind the economics of research. The marketplace controls the focus of research. When
managed-care economics dictated a massive swing to brief, symptom-oriented therapy,
reports from a multitude of well-funded research projects on brief therapy began to appear
in the literature. At the same time, the bottom dropped out of funding sources for research
on longer-term therapy, despite a strong clinical consensus about the importance of such
research. In time we expect that this trend will be reversed and that more investigation of
the effectiveness of psychotherapy in the real world of practice will be undertaken to
supplement the knowledge accruing from randomized controlled trials of brief therapy.
Another consideration is that, unlike in the physical sciences, many aspects of
psychotherapy inherently defy quantification. Psychotherapy is both art and science;
research findings may ultimately shape the broad contours of practice, but the human
encounter at the center of therapy will always be a deeply subjective, nonquantifiable
experience.
One of the most important underlying assumptions in this text is that interpersonal
interaction within the here-and-now is crucial to effective group therapy. The truly potent
therapy group first provides an arena in which clients can interact freely with others, then
helps them identify and understand what goes wrong in their interactions, and ultimately
enables them to change those maladaptive patterns. We believe that groups based solely on
other assumptions, such as psychoeducational or cognitive-behavioral principles, fail to
reap the full therapeutic harvest. Each of these forms of group therapy can be made even
more effective by incorporating an awareness of interpersonal process.
This point needs emphasis: It has great relevance for the future of clinical practice. The
advent of managed care will ultimately result in increased use of therapy groups. But, in
their quest for efficiency, brevity, and accountability, managed-care decision makers may
make the mistake of decreeing that some distinct orientations (brief, cognitive-behavioral,
symptom-focused) are more desirable because their approach encompasses a series of
steps consistent with other efficient medical approaches: the setting of explicit, limited
goals; the measuring of goal attainment at regular, frequent intervals; a highly specific
treatment plan; and a replicable, uniform, manual-driven, highly structured therapy with a
precise protocol for each session. But do not mistake the appearance of efficiency for true
effectiveness.

In this text we discuss, in depth, the extent and nature of the interactional focus and its
potency in bringing about significant character and interpersonal change. The interactional
focus is the engine of group therapy, and therapists who are able to harness it are much
better equipped to do all forms of group therapy, even if the group model does not
emphasize or acknowledge the centrality of interaction.
Initially I was not eager to undertake the considerable task of revising this text. The
theoretical foundations and technical approach to group therapy described in the fourth
edition remain sound and useful. But a book in an evolving field is bound to age sooner
than later, and the last edition was losing some of its currency. Not only did it contain
dated or anachronistic allusions, but also the field has changed. Managed care has settled
in by now, DSM-IV has undergone a text revision (DSM-IV-TR), and a decade of clinical
and research literature needed to be reviewed and assimilated into the text. Furthermore,
new types of groups have sprung up and others have faded away. Cognitive-behavioral,
psychoeducational, and problem-specific brief therapy groups are becoming more
common, so in this revision we have made a special effort throughout to address the
particular issues germane to these groups.
The first four chapters of this text discuss eleven therapeutic factors. Chapter 1 covers
instillation of hope, universality, imparting information, altruism, the corrective
recapitulation of the primary family group, the development of socializing techniques, and
imitative behavior. Chapters 2 and 3 present the more complex and powerful factors of
interpersonal learning and cohesiveness. Recent advances in our understanding of
interpersonal theory and the therapeutic alliance that can strengthen therapist effectiveness
have influenced our approach to these two chapters.
Chapter 4 discusses catharsis and existential factors and then attempts a synthesis by
addressing the comparative importance and the interdependence of all eleven therapeutic
factors.
The next two chapters address the work of the therapist. Chapter 5 discusses the tasks of
the group therapist—especially those germane to shaping a therapeutic group culture and
harnessing the group interaction for therapeutic benefit. Chapter 6 describes how the
therapist must first activate the here-and-now (that is, plunge the group into its own
experience) and then illuminate the meaning of the here-and-now experience. In this
edition we deemphasize certain models that rely on the elucidation of group-as-a-whole
dynamics (for example, the Tavistock approach)—models that have since proven
ineffective in the therapy process. (Some omitted material that may still interest some
readers will remain available at www.yalom.com.)
While chapters 5 and 6 address what the therapist must do, chapter 7 addresses how the
therapist must be. It explicates the therapist’s role and the therapist’s use of self by
focusing on two fundamental issues: transference and transparency. In previous editions, I
felt compelled to encourage therapist restraint: Many therapists were still so influenced by
the encounter group movement that they, too frequently and too extensively, “let it all
hang out.” Times have changed; more conservative forces have taken hold, and now we
feel compelled to discourage therapists from practicing too defensively. Many

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contemporary therapists, threatened by the encroachment of the legal profession into the
field (a result of the irresponsibility and misconduct of some therapists, coupled with a
reckless and greedy malpractice industry), have grown too cautious and impersonal.
Hence we give much attention to the use of the therapist’s self in psychotherapy.
Chapters 8 through 14 present a chronological view of the therapy group and emphasize
group phenomena and techniques that are relevant to each stage. Chapters 8 and 9, on
client selection and group composition, include new research data on group therapy
attendance, dropouts, and outcomes. Chapter 10, which describes the practical realities of
beginning a group, includes a lengthy new section on brief group therapy, presents much
new research on the preparation of the client for group therapy. The appendix contains a
document to distribute to new members to help prepare them for their work in the therapy
group.
Chapter 11 addresses the early stages of the therapy group and includes new material on
dealing with the therapy dropout. Chapter 12 deals with phenomena encountered in the
mature phase of the group therapy work: subgrouping, conflict, self-disclosure, and
termination.
Chapter 13, on problem members in group therapy, adds new material to reflect
advances in interpersonal theory. It discusses the contributions of intersubjectivity,
attachment theory, and self psychology. Chapter 14 discusses specialized techniques of the
therapist, including concurrent individual and group therapy (both combined and
conjoint), co-therapy, leaderless meetings, dreams, videotaping, and structured exercises,
the use of the written summary in group therapy, and the integration of group therapy and
twelve-step programs.
Chapter 15, on specialized therapy groups, addresses the many new groups that have
emerged to deal with specific clinical syndromes or clinical situations. It presents the
critically important principles used to modify traditional group therapy technique in order
to design a group to meet the needs of other specialized clinical situations and populations,
and describes the adaptation of cognitive-behavioral and interpersonal therapy to groups.
These principles are illustrated by in-depth discussions of various groups, such as the
acute psychiatric inpatient group and groups for the medically ill (with a detailed
illustration of a group for patients with cancer). Chapter 15 also discusses self-help groups
and the youngest member of the group therapy family—the Internet support group.
Chapter 16, on the encounter group, presented the single greatest challenge for this
revision. Because the encounter group qua encounter group has faded from contemporary
culture, we considered omitting the chapter entirely. However, several factors argue
against an early burial: the important role played by the encounter movement groups in
developing research technology and the use of encounter groups (also known as process
groups, T-groups (for “training”), or experiential training groups) in group psychotherapy
education. Our compromise was to shorten the chapter considerably and to make the entire
fourth edition chapter available at www.yalom.com for readers who are interested in the
history and evolution of the encounter movement.
Chapter 17, on the training of group therapists, includes new approaches to the

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supervision process and on the use of process groups in the educational curriculum.
During the four years of preparing this revision I was also engaged in writing a novel,
The Schopenhauer Cure, which may serve as a companion volume to this text: It is set in a
therapy group and illustrates many of the principles of group process and therapist
technique offered in this text. Hence, at several points in this fifth edition, I refer the
reader to particular pages in The Schopenhauer Cure that offer fictionalized portrayals of
therapist techniques.
Excessively overweight volumes tend to gravitate to the “reference book” shelves. To
avoid that fate we have resisted lengthening this text. The addition of much new material
has mandated the painful task of cutting older sections and citations. (I left my writing
desk daily with fingers stained by the blood of many condemned passages.) To increase
readability, we consigned almost all details and critiques of research method to footnotes
or to notes at the end of the book. The review of the last ten years of group therapy
literature has been exhaustive.

Most chapters contain 50–100 new references. In several locations throughout the book,
we have placed a dagger (†) to indicate that corroborative observations or data exist for
suggested current readings for students interested in that particular area. This list of
references and suggested readings has been placed on my website, www.yalom.com.

http://www.yalom.com

Acknowledgments
(Irvin Yalom)
I am grateful to Stanford University for providing the academic freedom, library
facilities, and administrative staff necessary to accomplish this work. To a masterful
mentor, Jerome Frank (who died just before the publication of this edition), my thanks for
having introduced me to group therapy and for having offered a model of integrity,
curiosity, and dedication. Several have assisted in this revision: Stephanie Brown, Ph.D.
(on twelve-step groups), Morton Lieberman, Ph.D. (on Internet groups), Ruthellen
Josselson, Ph.D. (on group-as-a-whole interventions), David Spiegel (on medical groups),
and my son Ben Yalom, who edited several chapters.

(Molyn Leszcz)
I am grateful to the University of Toronto Department of Psychiatry for its support in
this project. Toronto colleagues who have made comments on drafts of this edition and
facilitated its completion include Joel Sadavoy, M.D., Don Wasylenki, M.D., Danny
Silver, M.D., Paula Ravitz, M.D., Zindel Segal, Ph.D., Paul Westlind, M.D., Ellen
Margolese, M.D., Jan Malat, M.D., and Jon Hunter, M.D. Liz Konigshaus handled the
painstaking task of word-processing, with enormous efficiency and unyielding good
nature. Benjamin, Talia, and Noah Leszcz, my children, and Bonny Leszcz, my wife,
contributed insight and encouragement throughout.

Chapter 1
THE THERAPEUTIC FACTORS
Does group therapy help clients? Indeed it does. A persuasive body of outcome research
has demonstrated unequivocally that group therapy 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 approach the most vexing and controversial problems
of psychotherapy. Once identified, the crucial aspects of the process of change will
constitute 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
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 interpersonal
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 interwoven 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 separately. Moreover, these factors may
represent different parts of the change process: some factors (for example, self-
understanding) 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.† Although the same therapeutic factors operate in
every type of therapy group, their interplay and differential importance can vary widely
from group to group. Furthermore, because of individual differences, participants in the
same group benefit from widely different clusters of therapeutic factors.†
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 clinicians and researchers have arrived at a different,
and also arbitrary, clusters 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 inconsistent 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 answers will be determined largely by their particular school of
conviction. 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 successful group leaders
attributed their success to factors that were irrelevant 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 supposed. 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 superficial factors and neglect some profound healing forces
that may be beyond their awareness? Will their responses not be influenced by a variety of
factors 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 patients 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 psychotherapy. 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 Another 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.† 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 untapped 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 sorting questionnaires
provide easy data but often miss the nuances and the richness of the clients’ experience.
The more the questioner can enter into the experiential world of the client, the more lucid
and meaningful the report of the therapy experience becomes. To the degree that the
therapist is able to suppress personal bias and avoid influencing the client’s responses, 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 important method of
evaluating the therapeutic factors: the systematic research approach. The most common
research strategy by far is to correlate in-therapy variables with outcome in therapy. By
discovering which variables 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 measurement of outcome
is itself a methodological morass, and the selection and measurement of the in-therapy
variables are equally problematic.a10
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 deepened by other clinical researchers. For
my part, I am satisfied that they derive 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 psychotherapy. 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 therapist have similar expectations of the treatment.12 The power of expectations
extends beyond imagination alone. Recent brain imaging studies demonstrate that the
placebo is not inactive but can have a direct physiological effect on the brain.13
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 orientation, in which the therapist reinforces positive
expectations, corrects negative 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 individuals 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 important it was for them to
have observed the improvement of others. Remarkably, hope can be a powerful force even
in groups of individuals combating advanced cancer who lose cherished group members to
the disease. 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 informing 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 believe 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 individually, 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), Survivors 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 meetings 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 Alcoholics
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.
Substance abuse treatment programs commonly mobilize hope in participants 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 individuals 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 medical outcomes, reduces health care costs,
promotes the individual’s sense of self-efficacy, and often makes group interventions
superior to individual 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 unusual 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 experiences nor avail themselves of the opportunity to confide in,
and ultimately 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 report 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 cliché “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 experience of other people.
I have heard group members reveal such acts as incest, 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 disclosure opened by
one group member’s trust or courage. Long ago Freud noted that the staunchest taboos
(against incest and patricide) were constructed precisely because these very impulses are
part of the human being’s deepest nature.
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 opportunity 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 sentiments, 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 denominators between
individuals are clearly evident, and the members of a therapy group soon perceive their
similarities to one another. An example is illustrative: For many years I asked members of
T-groups (these are nonclients—primarily medical students, psychiatric residents, nurses,
psychiatric 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 conviction 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 category 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.b
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
Members of sexual abuse groups, too, profit enormously from the experience 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 predominantly Caucasian group may feel
excluded because of different cultural attitudes toward disclosure, interaction, and
affective expression. Therapists must help the group move past a focus on concrete
cultural differences 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 lacking 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 borders; 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 instruction about
mental health, mental illness, and general psychodynamics given by the therapists as well
as advice, suggestions, or direct guidance from either the therapist or other group
members.
Didactic Instruction
Most participants, 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 psychotherapy. 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 symptoms and disability.24
Marsh, writing in the 1930s, also believed in the importance of psychoeducation and
organized classes for his patients, complete with lectures, homework, and grades.25
Recovery, Inc., the nation’s oldest and largest self-help program for current 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, Mental 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 example, the value of “spotting”
troublesome and self-undermining behaviors; 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 information. Groups
such as Adult Survivors of Incest, Parents Anonymous, 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 important.
The ideal context is one of partnership and collaboration, rather than prescription and
subordination.
Recent group therapy literature abounds with descriptions of specialized groups for
individuals who have some specific disorder or face some 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 misinterprets the symptoms in ways that only
exacerbate them (“I’m dying” or “I’m going crazy”), thus perpetuating a vicious circle.
The therapists discuss 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 detailed instruction
on proper breathing techniques and progressive muscular relaxation.
Groups are often the setting in which new mindfulness- and meditation-based stress
reduction approaches are taught. By applying disciplined focus, members learn to become
clear, accepting, and nonjudgmental observers 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 fashioning 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 sequence 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
example, the acute anguish they will feel with each significant date (holidays,
anniversaries, and birthdays) during the first year of bereavement. Psychoeducational
groups for women with primary breast cancer provide members with information about
their illness, treatment options, and future risks as well as recommendations for a healthier
lifestyle. Evaluation of the outcome of these groups shows that participants demonstrate
significant 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 group, such as a preparatory session
intended to clarify important reasons for psychological dysfunction and to provide
instruction in methods 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 patterns, 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 religious or scientific. The explanation of a
phenomenon is the first step toward 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 producing anxiety. The
awareness that one is not one’s own helmsman, she points out, that one’s perceptions and
behavior are controlled by irrational 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 opposed to withdrawing in demoralized avoidance, is enormously helpful.
These responses not only appeal to our common sense but, as contemporary
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 symptoms may so compound the total
dysphoria that effective exploration becomes 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 dynamic 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 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 relationships
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 beneficial, 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 reciprocate to others who are
equally needy. Some group members are so intent 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 excessively
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 guidance. 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 program 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
reverse, 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 alternative suggestions about how to achieve a desired goal.53
Psychoeducation 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 people 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 terrible 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!”c
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 reciprocal giving-receiving
sequence, but also in profiting from something intrinsic 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 refreshing 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
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
remains the paid professional; the other members represent the real world and can be
counted on for spontaneous and truthful reactions and feedback. 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 dismissing 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 suggestion 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, 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.†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
authority /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 possible. 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 reactions associated
with parental/authority figures: some members become helplessly dependent on the
leaders, whom they imbue with unrealistic knowledge and power; other 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 energy 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 effort to appease
the leaders and the other members.
Obviously, similar phenomena occur in individual therapy, but the group provides a
vastly greater number and variety of recapitulative possibilities. 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 herself 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 welcomed 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 interpretation 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? Absolutely not! These
very criticisms—which had roots stretching down into her early relationships with her
siblings—did not constitute valid objections to group therapy. Quite the contrary: the
group format was particularly 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 patterns 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 established. 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 development of social skills in, for example, groups preparing
hospitalized patients 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 relationships, the group often represents the
first opportunity for accurate interpersonal feedback. Many lament their inexplicable
loneliness: group therapy provides a rich opportunity for members to learn how they
contribute 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 obsessive 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 obviously involves far
more than the simple recognition and conscious, deliberate 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 initial phases of therapeutic change. They permit the clients to
understand that there is a huge discrepancy between their intent and their actual impact on
others.†
Frequently senior members of a therapy group acquire highly sophisticated social skills:
they are attuned to process (see chapter 6); they have learned how to be helpfully
responsive to others; they have acquired methods 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 interactions, 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 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 themselves on aspects of the other group members as well as of the therapist. 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 difficult 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 reinforcement, has experimentally demonstrated that imitation is an
effective therapeutic force.†64 In group therapy it is not uncommon for a member to
benefit by observing the therapy of another member with a similar problem 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 therapists. 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
uncommon 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.

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 transference, and the corrective emotional experience. But it
also represents processes unique to the group setting that unfold only as a result of specific
work on the part of the therapist. To define the concept of interpersonal 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 relationships among members and
that the need to belong is a powerful, fundamental, and pervasive motivation.1
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.
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 separation 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 “relational 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 favorably, 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 consequences 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 integration 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 psychotherapy. †9 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 psychotherapy 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 renderings of his work into plain English);13 for another, his work has so
pervaded contemporary psychotherapeutic thought that his original writings seem overly
familiar or obvious. However, with the recent focus on integrating cognitive and
interpersonal approaches in individual therapy and in group therapy, interest in his
contributions have resurged.14 Kiesler argues in fact that the interpersonal frame is the
most appropriate model within which therapists can meaningfully synthesize cognitive,
behavioral, and psychodynamic approaches—it is the most comprehensive of the
integrative psychotherapies.†15
Sullivan’s formulations are exceedingly helpful for understanding the group therapeutic
process. Although a comprehensive discussion of interpersonal 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 survival. 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 appraisals 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, disparaging 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 elderly
—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 occurs 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 former’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 individual’s distorted
view of the therapist but to all interpersonal relationships (including, of course, distorted
relationships among group members). Second, the theory of origin is broader: parataxic
distortion is constituted not only of the simple transferring onto contemporary
relationships 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 difference in origins, transference and parataxic
distortion may be considered operationally identical. Furthermore, many therapists today
use the term transference to refer to all interpersonal distortions rather than confining its
use to the client-therapist relationship (see chapter 7).
The transference distortions emerge from a set of deeply stored memories of early
interactional experiences.19 These memories contribute to the construction of an internal
working model that shapes the individual’s attachment 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 others. 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 independence, and subordinate herself to the emotional needs of others.†
Psychotherapy may present her first opportunity to disconfirm her rigid and limiting
interpersonal road map.
Interpersonal (that is, parataxic) distortions tend to be self-perpetuating. For example,
an individual with a derogatory, debased self-image may, through selective inattention or
projection, incorrectly perceive another to be harsh and rejecting. Moreover, the process
compounds itself because that individual may then gradually develop mannerisms and
behavioral traits—for example, servility, defensive antagonism, or condescension—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 certain 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 interpersonal
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 interpersonal evaluations with
those of others. Consensual validation is a particularly 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 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.† “Mental disorder” also
consists of interpersonal processes that are either inadequate to the social situation or
excessively complex because the individual is relating to others 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 correction 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 Psychiatric 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 interpersonal 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 parent and child
group psychotherapy interventions that address childhood conduct disorders and antisocial
behavior. Poor communication of children’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 solving, 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 explicitly for help in their interpersonal relationships.
Yet I have observed that the therapeutic goals of clients often undergo a shift after a
number of sessions. Their initial goal, relief of suffering, is modified and eventually
replaced 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 client concerns and aspirations into interpersonal ones may
need to take place earlier, at the assessment and preparation phase (see chapter 10).31
The goal shift from relief of suffering to change in interpersonal functioning 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 therapeutic 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 interpersonal 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 express anger, hypersensitivity to separation—and then
addresses those interpersonal issues in therapy.
Sullivan’s statement of the overall process and goals of individual therapy is deeply
consistent with those of interactional group therapy. This interpersonal and relational
focus is a defining strength of group therapy.† The emphasis on the client’s understanding
of the past, of the genetic development 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 integral part of the
fabric of psychiatric thought that it needs no further underscoring. 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,
unacceptable 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 family 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 not knowing how to speak to the dying, by not wanting to upset them or themselves. I
agree with Elisabeth Kübler-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 demeanor, 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 nothing 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 approaches are beginning to address these specific concerns of the
terminally ill—their fear of isolation and their desire to retain dignity within their
relationships.† Consider the outcasts—those individuals thought to be so inured to
rejection that their interpersonal needs have become heavily 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
technician 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, extragroup 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 attention 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 but professionally
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 vehemently 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 members ventured a choice. Nevertheless, the group
shifted to an interactional level and developed a degree of tension, involvement, and
exhilaration 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 hardened, indifferent to the subtleties of
interpersonal approval and disapproval. 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 exploited
by others? To whom could she complain of the burdens of a ninetymillion-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 experience 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. Believe 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 development, mature
functioning, psychopathology, and psychiatric treatment 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 therapy: the concept that mental illness emanates from
disturbed interpersonal 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 necessary to understand the therapeutic factor of
interpersonal learning.
THE CORRECTIVE EMOTIONAL EXPERIENCE

In 1946, Franz Alexander, when describing the mechanism of psychoanalytic 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 corrective 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 reactions, 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
between 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 beliefs. 36 When such
discomfirmation occurs, change can be dramatic: clients express more emotion, recall
more personally relevant and formative experiences, 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 inappropriateness of his or her
interpersonal reactions—are as crucial in group therapy as in individual therapy, and
possibly more so because the group setting offers far more opportunities for the generation
of corrective emotional experiences. In the individual setting, the corrective emotional
experience, valuable as it is, may be harder to come by, because the client-therapist
relationship is more insular and the client is more able to dispute the spontaneity, 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 emotional 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 examination 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 described by Frank
and Ascher)39 involves a sudden expression of strong dislike 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 catastrophe ensued:
no one left or died; the roof did not collapse.
4. Reality testing ensued. The client realized either that the anger expressed 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 accounting either for the inappropriate affect or for the prior
avoidance of affect experience or expression.
5. The client was enabled to interact more freely and to explore interpersonal
relationships more deeply.
Thus, when I see two group members in conflict with one another, I believe 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 particularly 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 example, 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, engulfment, 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 members 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 feelings and
behavior or of the inappropriateness of avoiding certain interpersonal behavior.
5. The ultimate facilitation of the individual’s ability to interact with others more
deeply and honestly.
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 implications of that emotional experience.† 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 Barbara would accuse Alice of ignoring and rejecting her.
In this meeting, however, Barbara used a more gentle tone and asked Alice about
the meaning of her silence. Alice responded that she was listening carefully and
thinking about how much they had in common. She then added that Barbara’s
more gentle inquiry allowed her to give voice to her thoughts rather than defend
herself against the charge of not caring, a sequence that had ended badly for them
both in earlier sessions. The seemingly small but vitally important shift in
Barbara’s capacity to approach Alice empathically created an opportunity for
repair rather than repetition.
This formulation has direct relevance to a key concept of group therapy, the here-and-
now, which I will discuss in depth in chapter 6. Here I will state only this basic premise:
When the therapy group focuses on the here-and-now, it increases in power and
effectiveness.

But if the here-and-now focus (that is, a focus on what is happening in this room in the
immediate present) is to be therapeutic, it must have two components: the group members
must experience one another with as much spontaneity and honesty as possible, and they
must also reflect back on that experience. This reflecting back, this self-reflective 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 psychotherapy was conceived
in that very error: the first description of dynamic 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
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: emotional 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-siècle
cathartic treatment still lives today in the approaches of primal scream, bioenergetics, and
the many group leaders who place an exaggerated 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 emotional-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
(expression and experiencing of strong affect, self-disclosure, giving and receiving
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 experience were as likely as successful members to value highly the
emotional incidents of the group.
What types of experiences did differentiate the successful from the unsuccessful
members? There was clear evidence that a cognitive component was essential; some type
of cognitive map was needed, some intellectual 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 enough time, group members will
begin to be themselves: they will interact 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 detailed history of their pathology: they will sooner or
later enact it before the other group members’ eyes. Furthermore, their behavior serves as
accurate 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 character 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 interpersonal 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
difficulties are more subtle, such as individuals who quietly exploit others, those who
achieve intimacy to a point but then, becoming frightened, disengage themselves, or those
who pseudo-engage, maintaining a subordinate, compliant position.
The initial business of a group usually consists of dealing with the members whose
pathology is most interpersonally blatant. Some interpersonal 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 therapeutic advantage maladaptive interpersonal behavior as seen in the social
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.d
The Grand Dame

Valerie, a twenty-seven-year-old musician, sought therapy with me primarily 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
interaction 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
demoralization because of the ineffectiveness of a problem-solving, historical 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 entrance, 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 solipsistic 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 subscription 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 insisted on serving as confidante and go-between, thus
exerting considerable 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 consultation and referred her to a competent
therapist, a clinical psychologist. In the group Valerie congratulated me for the brilliant
tactic of sending her 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 undeserved tribute, then I would enter into a
dishonest collusion with Valerie; 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 relevant 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 engaged in sexual relations with
two; the third, a gay man, was not interested 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 manipulating the situation so that the
confessed transgressions became the sole responsibilities of the men in question, and not
herself. Each man performed as she bade him and, later in the meeting, received from her
a critical evaluation of his sexual performance. A few weeks later, Valerie let her 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 adulation, 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 humiliation and anger at having to “jump through a hoop” for her and at receiving
“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 understand more about your husband moving out!” and so on.
The others in the group, the female members and the therapists, shared the men’s feelings

about the wantonly destructive course of Valerie’s behavior—destructive 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 relationships and endeavors.
The Man Who Liked Robin Hood
Ron, a forty-eight-year-old attorney who was separated from his wife, entered therapy
because of depression, anxiety, and intense feelings of loneliness. 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, antagonistic 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 sequence: 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.
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
interact 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 experienced 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 little to offer you, or when I do extend some help, you reject it in one
fashion 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 members 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 romantically involved
with one of the female members; and (the final straw) he invited my co-therapist, a female
psychiatric resident, for a skiing weekend.
Furthermore, he refused to examine his behavior or to discuss these extragroup
meetings in the group, even though the pregroup preparation (see chapter 12) had
emphasized to all the members that such unexamined, 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 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 attracted to women who were attached to some powerful man. Even
his motives 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, because 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 alliances 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 resulted in the undermining
of the very reason he had come to therapy: to obtain 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 relating 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 interpersonal 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 mistreatment by her current boss and
boyfriend. Then one day an unusual incident 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 rule 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 neither by my denial nor by the unanimous consensus of the
other group members. Nor did she seem concerned in any way about the inconvenience
she had caused me. In the group discussion she grew defensive and acrimonious.
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 apparent that there were perceptual distortions at work: because of
her expectations 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 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 insensitive 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, exasperated, and uncaring toward her. This is a particularly
clear example of the concept of the self-fulfilling prophecy described on page 22. Linda
predicted that men would behave toward her in a certain way and then, unconsciously,
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 stimulated by a woman. Intrigued by this
conundrum, the group searched for an answer. They investigated his early life, sexual
habits, and fantasies. Finally, baffled, they turned to other issues in the group. As the
sessions continued, Allen seemed impassive and insensitive to his own and others’ pain.
On one occasion, for example, an unmarried member in great distress 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 responded 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 trying 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 group changed from that
of tolerated mascot to that of accepted compeer, 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 because 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 resembled 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, considered 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 impending 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
particularly 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 as he used them as equipment, as objects to
supply his life needs. It was not long before he had re-created in the group his habitual—
and desolate—interpersonal 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 sexualized 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 relationships 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 spontaneous interaction there is, the more rapid
and authentic will be the development 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 disorder, 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 manifest 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 anxious 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 pressure on the member to continue, regardless of
the person’s best interests. When members arranged contacts outside the group meeting,
Nancy became anxious at the threat to the integrity of the group. Sometimes members felt
smothered by Nancy. They drew away and expressed their objections to her phoning them
at home to check on their absence or lateness. Their insistence that she lighten her
demands on them simply aggravated Nancy’s anxiety, causing her to increase her
protective efforts.
Although she longed for comfort and safety in the group, it was, in fact, the very
appearance of these unsettling vicissitudes that made it possible 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 meaning and the dynamics of the behavior. The
therapist sees not only the behavior 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 transaction 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 feedback 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 beyond surface behavior and
become sensitive to one another’s internal experiences and underlying intentions.† 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.†
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 continuously 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 members’ 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 express 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 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 impact of that
behavior on others need to be revealed and processed if the members are to arrive at an
empathic understanding of one another. Empathic capacity is a key component of
emotional intelligence46 and facilitates 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 procrastination. 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 frustrated 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 fingernails”; “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 filling 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
application 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 procrastination for
what it was: a plaintive, anachronistic plea for a lost mother. Many things then fell into
place, including the dynamics behind Leonard’s depressions (which were also desperate
pleas for love), alcoholism, 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 meeting, the trained observer has a unique opportunity to
understand the dynamics 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 interpersonal 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 indispensable
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 person—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 example, a self-confident, assertive man evokes
strong feelings of fear, intense envy, or bitter resentment in another man, we can hardly
conclude that the response is reflective of the former’s pathology. There is a distinct
advantage in the therapy group format: because the group contains multiple observers, it is
easier to differentiate idiosyncratic and highly subjective responses from more objective
ones.
The emotional response of any single member is not sufficient; therapists 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. Ultimately therapists rely on the most valuable evidence of
all: their own emotional responses. Therapists must be able to attend to their own reactions
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 “unhooked”—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 meaningful feedback about the interpersonal transaction. From this
perspective, the thoughts, fantasies, and actual behavior elicited in the therapist by each
group member should be treated as gold. Our reactions are invaluable 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
therapeutic 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 subjective responses and objective assessments of the interactions.
Furthermore, group therapists may have a calm and privileged vantage point, since, unlike

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 interpersonal conflict and
distortion. How can we be certain these are not clouding 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 eight members perceives, observes, and interprets
differently. One common 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 differing 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 differently 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 helping others. Nowhere are such differences
more apparent than in the transference—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 microcosm.
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 accurately. 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 persuasive, but they are in
fact truth-distorting. In one sense, the group is artificial: 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 relationships are transient
—the end of the relationship is built into the social contract at the very beginning.
When faced with these arguments, I often think of Earl and Marguerite, 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.”
Neither 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. During 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 realized 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
experiences 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 members 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 reality.
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 describe 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.
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 interpersonal behavior:
their strengths, their limitations, their interpersonal 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 suffered 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 communicated the reasons for
rejection. Therefore, and this is important, clients have never learned to
discriminate between objectionable aspects of their behavior and a self-concept as
a totally unacceptable person. The therapy group, with its encouragement 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 becomes 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 potent is its impact; the more distant and
intellectualized the experience, 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;
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, abandonment, 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 diminishes. 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 Eventually
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 facilitation 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 mediator of change, I

wish to call attention to two concepts that deserve further discussion. Transference and
insight play too central a role in most formulations of the therapeutic process to be passed
over lightly. I rely heavily 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.
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 importance; 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 distortions to be examined in the therapy
process.
For many clients, perhaps for the majority, it is the most important relationship to work
through, because the therapist is the personification of parental images, of teachers, of
authority, of established tradition, of incorporated values. But most clients are also
conflicted in other interpersonal domains: for example, power, assertiveness, anger,
competitiveness with peers, intimacy, sexuality, generosity, greed, envy.
Considerable research emphasizes the importance many group members 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 indicate 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 therapist 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 encompassing 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, obsequious, and so on.
2. Clients may gain some understanding into their more complex interactional patterns
of behavior. Any of a vast number of patterns may become clear to them: for example, that
they exploit others, court constant admiration, seduce and then reject or withdraw,
compete relentlessly, plead for love, or relate only to the therapist or either the male or
female members.

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 because of the belief that different behavior
would bring about some catastrophe: one might be humiliated, scorned, destroyed, or
abandoned. Aloof, detached clients, for example, may understand that they shun closeness
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 individuals may dread the eruption of their
repressed, destructive rage.
4. A fourth level of insight, genetic insight, attempts to help clients understand how they
got to be the way they are. Through an exploration of the impact of early family and
environmental experiences, the client understands 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 “degree of inference” sequence. Furthermore,
“deep” has become equated with “profound” or “good,” and superficial with “trivial,”
“obvious,” or “inconsequential.” Psychoanalysts have, in the past, disseminated the belief
that the more profound the therapist, the deeper the interpretation (from the perspective of
early life events) and thus the more complete the treatment. There is, however, not a single
shred of evidence to support this conclusion.
Every therapist has encountered clients who have achieved considerable genetic insight
based on some accepted theory of child development or psychopathology—be it that of
Freud, Klein, Winnicott, Kernberg, or Kohut—and yet made no therapeutic progress. On
the other hand, it is commonplace for significant clinical change to occur in the absence of
genetic insight. Nor is there a demonstrated relationship between the acquisition of genetic
insight and the persistence of change. In fact, there is much reason to question the validity
of our most revered assumptions about the relationship between types of early experience
and adult behavior and character structure.52
For one thing, we must take into account recent neurobiological research into the
storage of memory. Memory is currently understood to consist of at least two forms, with
two distinct brain pathways.53 We are most familiar with the form of memory known as
“explicit memory.” This memory consists of recalled details, events, and the
autobiographical recollections of one’s life, and it has historically been the focus of
exploration and interpretation in the psychodynamic therapies. A second form of memory,
“implicit memory,” houses our earliest relational experiences, many of which precede our
use of language or symbols. This memory (also referred to as “procedural memory”)
shapes our beliefs about how to proceed in our relational world. Unlike explicit memory,
implicit memory is not fully reached through the usual psychotherapeutic dialogue but,
instead, through the relational and emotional component of therapy.
Psychoanalytic theory is changing as a result of this new understanding of memory.

Fonagy, a prominent analytic theorist and researcher, conducted an exhaustive review of
the psychoanalytic process and outcome literature. His conclusion: “The recovery of past
experience may be helpful, but the understanding of current ways of being with the other
is the key to change. For this, both self and other representations may need to alter and
this can only be done effectively in the here and now.”54 In other words, the actual
moment-to-moment experience of the client and therapist in the therapy relationship is the
engine of change.
A fuller discussion of causality would take us too far afield from interpersonal learning,
but I will return to the issue in chapters 5 and 6. For now, it is sufficient to emphasize that
there is little doubt that intellectual understanding lubricates the machinery of change. It is
important that insight—“sighting in”—occur, but in its generic, not its genetic, sense. And
psychotherapists need to disengage the concept of “profound” or “significant” intellectual
understanding from temporal considerations. Something that is deeply felt or has deep
meaning for a client may or—as is usually the case—may not be related to the unraveling
of the early genesis of behavior.

Chapter 3
GROUP COHESIVENESS
In this chapter I examine the properties of cohesiveness, the considerable evidence for
group cohesiveness as a therapeutic factor, and the various pathways through which it
exerts its therapeutic influence.
What is cohesiveness and how does it influence therapeutic outcome? The short answer
is that cohesiveness is the group therapy analogue to relationship in individual therapy.
First, keep in mind that a vast body of research on individual psychotherapy demonstrates
that a good therapist-client relationship is essential for a positive outcome. Is it also true
that a good therapy relationship is essential in group therapy? Here again, the literature
leaves little doubt that “relationship” is germane to positive outcome in group therapy. But
relationship in group therapy is a far more complex concept than relationship in individual
therapy. After all, there are only two people in the individual therapy transaction, whereas
a number of individuals, generally six to ten, work together in group therapy. It is not
enough to say that a good relationship is necessary for successful group therapy—we must
specify which relationship: The relationship between the client and the group therapist (or
therapists if there are co-leaders)? Or between the group member and other members? Or
perhaps even between the individual and the “group” taken as a whole?

Over the past forty years, a vast number of controlled studies of psychotherapy outcome
have demonstrated that the average person who receives psychotherapy is significantly
improved and that the outcome from group therapy is virtually identical to that of
individual therapy.1 Furthermore there is evidence that certain clients may obtain greater
benefit from group therapy than from other approaches, particularly clients dealing with
stigma or social isolation and those seeking new coping skills.2
The evidence supporting the effectiveness of group psychotherapy is so compelling that
it prompts us to direct our attention toward another question: What are the necessary
conditions for effective psychotherapy? After all, not all psychotherapy is successful. In
fact, there is evidence that treatment may be for better or for worse—although most
therapists help their clients, some therapists make some clients worse.3 Why? What makes
for successful therapy? Although many factors are involved, a proper therapeutic
relationship is a sine qua non for effective therapy outcome. 4 Research evidence
overwhelmingly supports the conclusion that successful therapy—indeed even successful
drug therapy—is mediated by a relationship between therapist and client that is
characterized by trust, warmth, empathic understanding, and acceptance.5 Although a
positive therapeutic alliance is common to all effective treatments, it is not easily or
routinely established. Extensive therapy research has focused on the nature of the
therapeutic alliance and the specific interventions required to achieve and maintain it.6

Is the quality of the relationship related to the therapist’s school of conviction? The
evidence says, “No.” Experienced and effective clinicians from different schools
(Freudian, nondirective, experiential, gestalt, relational, interpersonal, cognitive-
behavioral, psychodrama) resemble one another (and differ from nonexperts in their own
school) in their conception of the ideal therapeutic relationship and in the relationship they
themselves establish with their clients.7
Note that the engaged, cohesive therapeutic relationship is necessary in all
psychotherapies, even the so-called mechanistic approaches—cognitive, behavioral, or
systems-oriented forms of psychotherapy.8 A recent secondary analysis of a large
comparative psychotherapy trial, the National Institute of Mental Health’s (NIMH)
Treatment of Depression Collaborative Research Program, concluded that successful
therapy, whether it was cognitive-behavioral therapy or interpersonal therapy, required
“the presence of a positive attachment to a benevolent, supportive, and reassuring
authority figure.”9 Research has shown that the client-therapist bond and the technical
elements of cognitive therapy are synergistic: a strong and positive bond in itself
disconfirms depressive beliefs and facilitates the work of modifying cognitive distortions.
The absence of a positive bond renders technical interventions ineffective or even
harmful.10
As noted, relationship plays an equally critical role in group psychotherapy. But the
group therapy analogue of the client-therapist relationship in individual therapy must be a
broader concept, encompassing the individual’s relationship to the group therapist, to the
other group members, and to the group as a whole.† At the risk of courting semantic
confusion, I refer to all of these relationships in the group with the term “group
cohesiveness.” Cohesiveness is a widely researched basic property of groups that has been
explored in several hundred research articles. Unfortunately, there is little cohesion in the
literature, which suffers from the use of different definitions, scales, subjects, and rater
perspectives.11
In general, however, there is agreement that groups differ from one another in the
amount of “groupness” present. Those with a greater sense of solidarity, or “we-ness,”
value the group more highly and will defend it against internal and external threats. Such
groups have a higher rate of attendance, participation, and mutual support and will defend
the group standards much more than groups with less esprit de corps. Nonetheless it is
difficult to formulate a precise definition. A recent comprehensive and thoughtful review
concluded that cohesiveness “is like dignity: everyone can recognize it but apparently no
one can describe it, much less measure it.”12 The problem is that cohesiveness refers to
overlapping dimensions. On the one hand, there is a group phenomenon—the total esprit
de corps; on the other hand, there is the individual member cohesiveness (or, more strictly,
the individual’s attraction to the group).13
In this book, cohesiveness is broadly defined as the result of all the forces acting on all
the members such that they remain in the group,14 or, more simply, the attractiveness of a
group for its members.15 Members of a cohesive group feel warmth and comfort in the

group and a sense of belongingness; they value the group and feel in turn that they are
valued, accepted, and supported by other members.16†
Esprit de corps and individual cohesiveness are interdependent, and group cohesiveness
is often computed simply by summing the individual members’ level of attraction to the
group. Newer methods of measuring group cohesiveness from raters’ evaluations of group
climate make for greater quantitative precision, but they do not negate the fact that group
cohesiveness remains a function and a summation of the individual members’ sense of
belongingness.17 Keep in mind that group members are differentially attracted to the group
and that cohesiveness is not fixed—once achieved, forever held—but instead fluctuates
greatly during the course of the group.18 Early cohesion and engagement is essential for
the group to encompass the more challenging work that comes later in the group’s
development, as more conflict and discomfort emerges.19 Recent research has also
differentiated between the individual’s sense of belonging and his or her appraisal of how
well the entire group is working. It is not uncommon for an individual to feel “that this
group works well, but I’m not part of it.”20 It is also possible for members (for example
eating disorder clients) to value the interaction and bonding in the group yet be
fundamentally opposed to the group goal.21
Before leaving the matter of definition, I must point out that group cohesiveness is not
only a potent therapeutic force in its own right. It is a precondition for other therapeutic
factors to function optimally. When, in individual therapy, we say that it is the relationship
that heals, we do not mean that love or loving acceptance is enough; we mean that an ideal
therapist-client relationship creates conditions in which the necessary risk taking,
catharsis, and intrapersonal and interpersonal exploration may unfold. It is the same for
group therapy: cohesiveness is necessary for other group therapeutic factors to operate.
THE IMPORTANCE OF GROUP COHESIVENESS
Although I have discussed the therapeutic factors separately, they are, to a great degree,
interdependent. Catharsis and universality, for example, are not complete processes. It is
not the sheer process of ventilation that is important; it is not only the discovery that
others have problems similar to one’s own and the ensuing disconfirmation of one’s
wretched uniqueness that are important. It is the affective sharing of one’s inner world and
then the acceptance by others that seem of paramount importance. To be accepted by
others challenges the client’s belief that he or she is basically repugnant, unacceptable, or
unlovable. The need for belonging is innate in us all. Both affiliation within the group and
attachment in the individual setting address this need.22 Therapy groups generate a
positive, self-reinforcing loop: trust–self-disclosure–empathy–acceptance–trust.23 The
group will accept an individual, provided that the individual adheres to the group’s
procedural norms, regardless of past life experiences, transgressions, or social failings.
Deviant lifestyles, history of prostitution, sexual perversion, heinous criminal offenses—

all of these can be accepted by the therapy group, so long as norms of nonjudgmental
acceptance and inclusiveness are established early in the group.
For the most part, the disturbed interpersonal skills of our clients have limited their
opportunities for effective sharing and acceptance in intimate relationships. Furthermore,
some members are convinced that their abhorrent impulses and fantasies shamefully bar
them from social interaction. † I have known many isolated clients for whom the group
represented their only deeply human contact. After just a few sessions, they 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 the warm sense of belonging and acceptance.
As one successful client looking back over two and a half years of 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, creating durable relationships—perhaps for the
first time in their lives. One group member commented that he had always attributed his
aloneness to some unidentified, intractable, repugnant character failing. It was only after
he stopped missing meetings regularly because of his discouragement and sense of futility
that he discovered the responsibility he exercised for his own aloneness: relationships do
not inevitably wither—his had been doomed largely by his choice to neglect them.
Some individuals internalize the group: “It’s as though the 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 are disinclined to let the group down.24
Membership, acceptance, and approval in various groups are of the utmost importance
in the individual’s developmental sequence. The importance of belonging to childhood
peer groups, adolescent cliques, sororities or fraternities, or the proper social “in” group
can hardly be overestimated. Nothing seems to be of greater importance for the self-
esteem and well-being of the adolescent, for example, than to be included and accepted in
some social group, and nothing is more devastating than exclusion.25
Most of our clients, however, have an impoverished group history; they have never
been valuable and integral to a group. For these individuals, the sheer successful
negotiation of a group experience may in itself be curative. Belonging in the group raises
self-esteem and meets members’ dependency needs but in ways that also foster
responsibility and autonomy, as each member contributes to the group’s welfare and
internalizes the atmosphere of a cohesive group.26
Thus, in a number of ways, members of a therapy group come to mean a great deal to
one another. The therapy group, at first perceived as an artificial group that does not count,
may in fact come to count very much. I have known groups whose members experience

together severe depressions, psychoses, marriage, divorce, abortions, suicide, career shifts,
sharing of innermost thoughts, and incest (sexual activity among the group members). I
have seen a group physically carry one of its members to the hospital and seen many
groups mourn the death of members. I have seen members of cancer support groups
deliver eulogies at the funeral of a fallen group member. Relationships are often cemented
by moving or hazardous adventures. How many relationships in life are so richly layered?
Evidence
Empirical evidence for the impact of group cohesiveness is not as extensive or as
systematic as research documenting the importance of relationship in individual
psychotherapy. Studying the effect of cohesiveness is more complex27 because it involves
research on variables closely related to cohesion such as group climate (the degree of
engagement, avoidance, and conflict in the group)28 and alliance (the member-therapist
relationship).29 The results of the research from all these perspectives, however, point to
the same conclusion: relationship is at the heart of good therapy. This is no less important
in the era of managed care and 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 from external intrusion and control.30
I now turn to a survey of the relevant research on cohesion. (Readers who are less
interested in research methodology may wish to proceed directly to the summary section.)
• In an early study of former group psychotherapy clients in which members’
explanations of the therapeutic factors in their therapy were transcribed and
categorized, 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, 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.31
• In 1970, I 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.32 Since that time, a vast number of
studies using analogous designs have generated considerable data on clients’ views
of what aspects of group therapy have been most useful. I 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,33 observers rated the process
of each group session by scoring each member on five variables: acceptance,
activity, desensitivity, abreaction, and improvement. Weekly self-ratings were also
obtained from each member. Both the research raters and group members

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.34
• My colleagues and I evaluated the one-year outcome of all forty clients who had
started therapy in five outpatient groups.35 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
cohesiveness36 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 the twelfth weeks had
a better therapy outcome at the fiftieth week. The popularity finding, which in this
study correlated even more positively with outcome than did cohesiveness, is, as I
shall discuss shortly, relevant to group cohesiveness and sheds light on the
mechanism through which group cohesiveness mediates change.
• 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.37
• The quality of intermember relationships has also been well documented as an
essential ingredient in T-groups (also called sensitivity-training, process,
encounter, or experiential groups; see chapter 16). 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.38 The members who entered into the most two-person mutually
therapeutic relationships showed the most improvement during the course of the
group.39 Furthermore, the perceived relationship with the group leader was
unrelated to the extent of change.
• My colleagues M. A. Lieberman, M. Miles, and I conducted a study of 210 subjects
in eighteen encounter groups, encompassing ten ideological schools (gestalt,
transactional analysis, T-groups, Synanon, personal growth, Esalen,
psychoanalytic, marathon, psychodrama, encounter tape).40 (See chapter 16 for a
detailed discussion of this project.) Cohesiveness was assessed in several ways and
correlated with outcome.41 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 belongingness 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.42
• MacKenzie and Tschuschke, studying twenty clients in long-term inpatient groups,
differentiated members’ personal “emotional relatedness to the group” from their
appraisal of “group work” as a whole. The individual’s personal sense of belonging
correlated with future outcome, whereas the total group work scales did not.43
• S. 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 outcome.44
• A number of other studies have examined the role of the relationship between the
client and the group leader in group therapy. Marziali and colleagues45 examined
group cohesion and the client-group leader relationship in a thirty-session
manualized interpersonal therapy group of clients with borderline personality
disorder. Cohesion and member-leader relationship correlated strongly, supporting
Budman’s findings,46 and both positively correlated with outcome. However, the
member-group leader relationship measure was a more powerful predictor of
outcome. The relationship between client and therapist may be particularly
important for clients who have volatile interpersonal relationships and with whom
the therapist serves an important containing function.
• In a study of a short-term structured cognitive-behavioral therapy group for social
phobia47 the relationship with the therapist deepened over the twelve weeks of
treatment and correlated positively with outcome, but cohesion was static and not
related to outcome. In this study the group was a setting for therapy and not an
agent of therapy. Intermember bonds were not cultivated by the therapists, leading
the authors to conclude that in highly structured groups, what matters most is the
client-therapist collaboration around the therapy tasks.48
• 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
well-being and effort?49
• Outcomes in brief intensive American Group Psychotherapy Association Institute

training groups were influenced by higher levels of engagement. 50 Positive
outcomes may well be mediated by group engagement that fosters more
interpersonal communication and self-disclosure.51
Summary
I have cited evidence that group members value deeply the acceptance and support they
receive from their therapy group. Self-perceived therapy outcome is positively correlated
with attraction to the group. Highly cohesive groups have a better overall outcome than
groups with low esprit de corps. Both emotional connectedness and the experience of
group effectiveness contribute to group cohesiveness. Individuals with positive outcomes
have had more mutually satisfying relationships with other members. Highly cohesive
groups have greater levels of self-disclosure. 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.
The presence of cohesion early in each session as well as in the early sessions of the
group correlates with positive outcomes. It is critical that groups become cohesive and
that leaders be alert to each member’s personal experience of the group and address
problems with cohesion quickly. Positive client outcome is also correlated with group
popularity, a variable closely related to group support and acceptance. Although
therapeutic change is multidimensional, these findings taken together strongly support the
contention that group cohesiveness is an important determinant of positive therapeutic
outcome.
In addition to this direct evidence, there is considerable indirect evidence from research
with other types of groups. A plethora of studies demonstrate that in laboratory task
groups, high levels of group cohesiveness produce many results that may be considered
intervening therapy outcome factors. For example, group cohesiveness results in better
group attendance, greater participation of members, greater influenceability of members,
and many other effects. I will consider these findings in detail shortly, as I discuss the
mechanism by which cohesiveness fosters therapeutic change.
MECHANISM OF ACTION
How do group acceptance, group support, and trust help troubled individuals? Surely there
must be more to it than simple support or acceptance; therapists learn early in their careers
that love is not enough. Although the quality of the therapist-client relationship is crucial,
the therapist must do more than simply relate warmly and honestly to the client.52 The
therapeutic relationship creates favorable conditions for setting other processes in motion.

What other processes? And how are they important?
Carl Rogers’s deep insights into the therapeutic relationship are as relevant today as
they were nearly fifty years ago. Let us start our investigation by examining his views
about the mode of action of the therapeutic relationship in individual therapy. In his most
systematic description of the process of therapy, Rogers states that when the conditions of
an ideal therapist-client relationship exist, the following characteristic process is set into
motion:
1. The client is increasingly free in expressing his feelings.
2. He begins to test reality and to become more discriminatory in his feelings and
perceptions of his environment, his self, other persons, and his experiences.
3. He increasingly becomes aware of the incongruity between his experiences and his
concept of self.
4. He also becomes aware of feelings that have been previously denied or distorted in
awareness.
5. His concept of self, which now includes previously distorted or denied aspects,
becomes more congruent with his experience.
6. He becomes increasingly able to experience, without threat, the therapist’s
unconditional positive regard and to feel an unconditional positive self-regard.
7. He increasingly experiences himself as the focus of evaluation of the nature and
worth of an object or experience.
8. He reacts to experience less in terms of his perception of others’ evaluation of him
and more in terms of its effectiveness in enhancing his own development.53
Central to Rogers’s views is his formulation of an actualizing tendency, an inherent
tendency in all life to expand and to develop itself—a view stretching back to early
philosophic views and clearly enunciated a century ago by Nietzsche.54 It is the therapist’s
task to function as a facilitator and to create conditions favorable for self-expansion. The
first task of the individual is self-exploration: the examination of feelings and experiences
previously denied awareness.
This task is a ubiquitous stage in dynamic psychotherapy. Horney, for example,
emphasized the individual’s need for self-knowledge and self-realization, stating that the
task of the therapist is to remove obstacles in the path of these autonomous processes.55
Contemporary models recognize the same principle. Clients often pursue therapy with a
plan to disconfirm pathogenic beliefs that obstruct growth and development.56 In other
words, there is a built-in inclination to growth and self-fulfillment in all individuals. The
therapist does not have to inspirit clients with these qualities (as if we could!). Instead, our
task is to remove the obstacles that block the process of growth. And one way we do this
is by creating an ideal therapeutic atmosphere in the therapy group. A strong bond
between members not only directly disconfirms one’s unworthiness, it also generates
greater willingness among clients to self-disclose and take interpersonal risks. These

changes help deactivate old, negative beliefs about the self in relation to the world.57
There is experimental evidence that good rapport in individual therapy and its
equivalent (cohesiveness) in group therapy encourage the client to participate in a process
of reflection and personal exploration. For example, Truax,58 studying forty-five
hospitalized patients in three heterogeneous groups, demonstrated that participants in
cohesive groups were significantly more inclined to engage in deep and extensive self-
exploration. 59 Other research demonstrates that high cohesion is closely related to high
degrees of intimacy, risk taking, empathic listening, and feedback. 60 The group members’
recognition that their group is working well at the task of interpersonal learning produces
greater cohesion in a positive and self-reinforcing loop.61 Success with the group task
strengthens the emotional bonds in the group.
Perhaps cohesion is vital because many of our clients have not had the benefit of
ongoing solid peer acceptance in childhood. Therefore they find validation by other group
members a new and vital experience. Furthermore, acceptance and understanding among
members may carry greater power and meaning than acceptance by a therapist. Other
group members, after all, do not have to care, or understand. They’re not paid for it; it’s
not their “job.”62
The intimacy developed in a group may be seen as a counterforce in a technologically
driven culture that, in all ways—socially, professionally, residentially, recreationally—
inexorably dehumanizes relationships.63 In a world in which traditional boundaries that
maintain relationships are increasingly permeable and transient, there is a greater need
than ever for group belonging and group identity.64 The deeply felt human experience in
the group may be of great value to the individual, Rogers believes. Even if it creates no
visible carryover, no external change in behavior, group members may still experience a
more human, richer part of themselves and have this as an internal reference point. This
last point is worth emphasizing, for it is one of those gains of therapy—especially group
therapy—that enrich one’s interior life and yet may not, at least for a long period of time,
have external behavioral manifestations and thus may elude measurement by researchers
and consideration by managed health care administrators, who determine how much and
what type of therapy is indicated.
Group members’ acceptance of self and acceptance of other members are
interdependent; not only is self-acceptance basically dependent on acceptance by others,
but acceptance of others is fully possible only after one can accept oneself. This principle
is supported by both clinical wisdom and research.65 Members of a therapy group may
experience considerable self-contempt and contempt for others. A manifestation of this
feeling may be seen in the client’s initial refusal to join “a group of nuts” or reluctance to
become closely involved with a group of pained individuals for fear of being sucked into a
maelstrom of misery. A particularly evocative response to the prospect of group therapy
was given by a man in his eighties when he was invited to join a group for depressed
elderly men: it was useless, he said, to waste time watering a bunch of dead trees—his
metaphor for the other men in his nursing home.66

In my experience, all individuals seeking assistance from a mental health professional
have in common two paramount difficulties: (1) establishing and maintaining meaningful
interpersonal relationships, and (2) maintaining a sense of personal worth (self-esteem). It
is hard to discuss these two interdependent areas as separate entities, but since in the
preceding chapter I dwelled more heavily on the establishment of interpersonal
relationships, I shall now turn briefly to self-esteem.
Self-esteem and public esteem are highly interdependent.67 Self-esteem refers to an
individual’s evaluation of what he or she is really worth, and is indissolubly linked to that
person’s experiences in prior social relationships. Recall Sullivan’s statement: “The self
may be said to be made up of reflected appraisals.”68 In other words, during early
development, one’s perceptions of the attitudes of others toward oneself come to
determine how one regards and values oneself. The individual internalizes many of these
perceptions and, if they are consistent and congruent, relies on these internalized
evaluations for some stable measure of self-worth.
But, in addition to this internal reservoir of self-worth, people are, to a greater or lesser
degree, always concerned and influenced by the current evaluations of others—especially
the evaluation provided by the groups to which they belong. Social psychology research
supports this clinical understanding: the groups and relationships in which we take part
become incorporated in the self.69 One’s attachment to a group is multidimensional. It is
shaped both by the member’s degree of confidence in his attractiveness to the group—am
I a desirable member?—and the member’s relative aspiration for affiliation—do I want to
belong?
The influence of public esteem—that is, the group’s evaluation—on an individual
depends on several factors: how important the person feels the group to be; the frequency
and specificity of the group’s communications to the person about that public esteem; and
the salience to the person of the traits in question. (Presumably, considering the honest and
intense self-disclosure in therapy groups, the salience is very great indeed, since these
traits are close to a person’s core identity.) In other words, the more the group matters to
the person, and the more that person subscribes to the group values, the more he or she
will be inclined to value and agree with the group judgment.70 This last point has much
clinical relevance. The more attracted an individual is to the group, the more he or she will
respect the judgment of the group and will attend to and take seriously any discrepancy
between public esteem and self-esteem. A discrepancy between the two will create a state
of dissonance, which the individual will attempt to correct.
Let us suppose this discrepancy veers to the negative side—that is, the group’s
evaluation of the individual is less than the individual’s self-evaluation. How to resolve
that discrepancy? One recourse is to deny or distort the group’s evaluation. In a therapy
group, this is not a positive development, for a vicious circle is generated: the group, in the
first place, evaluates the member poorly because he or she fails to participate in the group
task (which in a therapy group consists of active exploration of one’s self and one’s
relationships with others). Any increase in defensiveness and communicational problems
will only further lower the group’s esteem of that particular member. A common method

used by members to resolve such a discrepancy is to devalue the group—emphasizing, for
example, that the group is artificial or composed of disturbed individuals, and then
comparing it unfavorably to some anchor group (for example, a social or occupational
group) whose evaluation of the member is different. Members who follow this sequence
(for example, the group deviants described in chapter 8) usually drop out of the group.
Toward the end of a successful course of group therapy, one group member reviewed
her early recollections of the group as follows: “For the longest time I told myself you
were all nuts and your feedback to me about my defensiveness and inaccessibility was
ridiculous. I wanted to quit—I’ve done that before many times, but I felt enough of a
connection here to decide to stay. Once I made that choice I started to tell myself that you
cannot all be wrong about me. That was the turning point in my therapy.” This is an
example of the therapeutic method of resolving the discrepancy for the individual: that is,
to raise one’s public esteem by changing those behaviors and attitudes that have been
criticized by the group. This method is more likely if the individual is highly attracted to
the group and if the public esteem is not too much lower than the self-esteem.
But is the use of group pressure to change individual behavior or attitudes a form of
social engineering? Is it not mechanical? Does it not neglect deeper levels of integration?
Indeed, group therapy does employ behavioral principles; psychotherapy is, in all its
variants, basically a form of learning. Even the most nondirective therapists use, at an
unconscious level, operant conditioning techniques: they signal desirable conduct or
attitudes to clients, whether explicitly or subtly.71
This process does not suggest that we assume an explicit behavioral, mechanistic view
of the client, however. Aversive or operant conditioning of behavior and attitudes is, in my
opinion, neither feasible nor effective when applied as an isolated technique. Although
clients often report lasting improvement after some disabling complaint is remedied by
behavioral therapy techniques, close inspection of the process invariably reveals that
important interpersonal relationships have been affected. Either the therapist-client
relationship in the behavioral and cognitive therapies has been more meaningful than the
therapist realized (and research evidence substantiates this),72 or some important changes,
initiated by the symptomatic relief, have occurred in the client’s social relationships that
have served to reinforce and maintain the client’s improvement. Again, as I have stressed
before, all the therapeutic factors are intricately interdependent. Behavior and attitudinal
change, regardless of origin, begets other changes. The group changes its evaluation of a
member; the member feels more self-satisfied in the group and with the group itself; and
the adaptive spiral described in the previous chapter is initiated.
A far more common occurrence in a psychotherapy group is a discrepancy in the
opposite direction: the group’s evaluation of a member is higher than the member’s self-
evaluation. Once again, the member is placed in a state of dissonance and once again will
attempt to resolve the discrepancy. What can a member in that position do? Perhaps the
person will lower the public esteem by revealing personal inadequacies. However, in
therapy groups, this behavior has the paradoxical effect of raising public esteem—
disclosure of inadequacies is a valued group norm and enhances acceptance by the group.

Another possible scenario, desirable therapeutically, occurs when group members
reexamine and alter their low level of self-esteem. An illustrative clinical vignette will
flesh out this formulation:
• Marietta, 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
unimaginativeness, her functioning 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 people in her community. She married a man
she considered repugnant but nonetheless a good man—certainly good enough for
her. Only in her sexual affairs, particularly when she had them 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 Marietta’s group behavior. She 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 found other, nonsexual, aspects of herself to
disclose and spoke openly of a broad array of her life concerns. Soon she found
herself increasingly valued by the other members. She gradually reexamined and
eventually disconfirmed her belief that she had little of value to offer. The
discrepancy between her public esteem and her self-esteem widened (that is, the
group valued her more than she regarded herself), 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.
The more therapy disconfirms the client’s negative self-image through new relational
experience, the more effective therapy will be.73
Self-Esteem, Public Esteem, and Therapeutic Change: Evidence
Group therapy research has not specifically investigated the relationship between public
esteem and shifts in self-esteem. However, an interesting finding from a study of
experiential groups (see chapter 16) was that members’ self-esteem decreased when public

esteem decreased.74 (Public esteem is measured by sociometric data, which involves
asking members to rank-order one another on several variables.) Researchers also
discovered that the more a group member underestimated his or her public esteem, the
more acceptable that member was to the other members. In other words, the ability to face
one’s deficiencies, or even to judge oneself a little harshly, increases one’s public esteem.
Humility, within limits, is far more adaptable than arrogance.
It is also interesting to consider data on group popularity, a variable closely related to
public esteem. The group members considered most popular by other members after six
and twelve weeks of therapy had significantly better therapy outcomes than the other
members at the end of one year.75 Thus, it seems that clients who have high public esteem
early in the course of a group are destined to have a better therapy outcome.
What factors seem to be responsible for the attainment of popularity in therapy groups?
Three variables, which did not themselves correlate with outcome, correlated significantly
with popularity:
1. Previous self-disclosure.76
2. Interpersonal compatibility:77 individuals who (perhaps fortuitously) have
interpersonal needs that happen to blend well with those of the other group
members become popular in the group.
3. Other sociometric measures; group members who were often chosen as leisure
companions and worked well with colleagues became popular in the group. A
clinical study of the most popular and least popular members revealed that popular
members tended to be young, well-educated, intelligent, and introspective. They
filled the leadership vacuum that occurs early in the group when the therapist
declines to assume the traditional leader role.78
The most unpopular group members were rigid, moralistic, nonintrospective, and least
involved in the group task. Some were blatantly deviant, attacking the group and isolating
themselves. Some schizoid members were frightened of the group process and remained
peripheral. A study of sixty-six group therapy members concluded that the less popular
members (that is, those viewed less positively by other members) were more inclined to
drop out of the group.79
Social psychology researchers have also investigated the attributes that confer higher
social status in social groups. The personality attribute of extraversion (measured by a
personality questionnaire, the NEO-PI)80 is a very strong predictor of popularity.81
Extraversion connotes the traits of active and energetic social engagement, that is, a
person who is upbeat and emotionally robust. Depue’s neurobiological research82 suggests
that such individuals invite others to approach them. The promise of the extravert’s
welcome response rewards and reinforces engagement.
The Lieberman, Yalom, and Miles encounter group study corroborated these
conclusions.83 Sociometric data revealed that the members with the more positive
outcomes were influential and engaged in behavior in close harmony with the encounter

group values of risk taking, spontaneity, openness, self-disclosure, expressivity, group
facilitation, and support. Evidence has emerged from both clinical and social-
psychological small-group research demonstrating that the members who adhere most
closely to group norms attain positions of popularity and influence.84 Members who help
the group achieve its tasks are awarded higher status.85
To summarize: Members who are popular and influential in therapy groups have a
higher likelihood of changing. They attain popularity and influence in the group by virtue
of their active participation, self-disclosure, self-exploration, emotional expression,
nondefensiveness, leadership, interest in others, and support of the group.
It is important to note that the individual who adheres to the group norms not only is
rewarded by increased public esteem within the group but also uses those same social
skills to deal more effectively with interpersonal problems outside the group. Thus,
increased popularity in the group acts therapeutically in two ways: by augmenting self-
esteem and by reinforcing adaptive social skills. The rich get richer. The challenge in
group therapy is helping the poor get richer as well.
Group Cohesiveness and Group Attendance
Continuation in the group is obviously a necessary, though not a sufficient, prerequisite for
successful treatment. Several studies indicate that clients who terminate early in the course
of group therapy receive little benefit.86 In one study, over fifty clients who dropped out of
long-term therapy groups within the first twelve meetings reported that they did so
because of some stress encountered in the group. They were not satisfied with their
therapy experience and they did not improve; indeed, many of these clients felt worse.87
Clients who remain in the group for at least several months have a high likelihood (85
percent in one study) of profiting from therapy.88
The greater a member’s attraction to the group, the more inclined that person will be to
stay in therapy groups as well as in encounter groups, laboratory groups (formed for some
research purpose), and task groups (established to perform some designated task).89 The
Lieberman, Yalom, and Miles encounter group study discovered a high correlation
between low cohesiveness and eventual dropping out from the group.90 The dropouts had
little sense of belongingness and left the group most often because they felt rejected,
attacked, or unconnected.
The relationship between cohesiveness and maintenance of membership has
implications for the total group as well. Not only do the least cohesive members terminate
membership and fail to benefit from therapy, but noncohesive groups with high member
turnover prove to be less therapeutic for the remaining members as well. Clients who drop
out challenge the group’s sense of worth and effectiveness.
Stability of membership is a necessary condition for effective shortand long-term
interactional group therapy. Although most therapy groups go through an early phase of

instability during which some members drop out and replacements are added, the groups
thereafter settle into a long, stable phase in which much of the solid work of therapy
occurs. Some groups seem to enter this phase of stability early, and other groups never
achieve it. Dropouts at times beget other dropouts, as other clients may terminate soon
after the departure of a key member. In a group therapy follow-up study, clients often
spontaneously underscored the importance of membership stability.91
In chapter 15, I will discuss the issue of cohesiveness in groups led in clinical settings
that preclude a stable long-term membership. For example, drop-in crisis groups or groups
on an acute inpatient ward rarely have consistent membership even for two consecutive
meetings. In these clinical situations, therapists must radically alter their perspectives on
the life development of the group. I believe, for example, that the appropriate life span for
the acute inpatient group is a single session. The therapist must strive to be efficient and to
offer effective help to as many members as possible during each single session.
Brief therapy groups pay a particularly high price for poor attendance, and therapists
must make special efforts to increase cohesiveness early in the life of the group. These
strategies (including strong pregroup preparation, homogeneous composition, and
structured interventions)92 will be discussed in chapter 15.
Group Cohesiveness and the Expression of Hostility
It would be a mistake to equate cohesiveness with comfort. Although cohesive groups
may show greater acceptance, intimacy, and understanding, there is evidence that they
also permit greater development and expression of hostility and conflict. Cohesive groups
have norms (that is, unwritten rules of behavior accepted by group members) that
encourage open expression of disagreement or conflict alongside support. In fact, unless
hostility can be openly expressed, persistent covert hostile attitudes may hamper the
development of cohesiveness and effective interpersonal learning. Unexpressed hostility
simply smolders within, only to seep out in many indirect ways, none of which facilitates
the group therapeutic process. It is not easy to continue communicating honestly with
someone you dislike or even hate. The temptation to avoid the other and to break off
communication is very great; yet when channels of communication are closed, so are any
hopes for conflict resolution and for personal growth.
This is as true on the megagroup—even the national—level as on the dyadic. The
Robbers’ Cave experiment, a famed research project conducted long ago, in the infancy of
group dynamics research,e offers experimental evidence still relevant for contemporary
clinical work.93 A camp of well-adjusted eleven-year-old boys was divided at the outset
into two groups that were placed in competition with each other in a series of contests.
Soon each group developed considerable cohesiveness as well as a deep sense of hostility
toward the other group. Any meaningful communication between the two groups became
impossible. If, for example, they were placed in physical proximity in the dining hall, the
group boundaries remained impermeable. Intergroup communication consisted of taunts,

insults, and spitballs.
How to restore meaningful communication between the members of the two groups?
That was the quest of the researchers. Finally they hit upon a successful strategy.
Intergroup hostility was relieved only when a sense of allegiance to a single large group
could be created. The researchers created some superordinate goals that disrupted the
small group boundaries and forced all the boys to work together in a single large group.
For example, a truck carrying food for an overnight hike stalled in a ditch and could be
rescued only by the cooperative efforts of all the boys; a highly desirable movie could be
rented only by the pooled contributions of the entire camp; the water supply was cut off
and could be restored only by the cooperative efforts of all campers.
The drive to belong can create powerful feelings within groups. Members with a strong
adherence to what is inside the group may experience strong pressure to exclude and
devalue who and what is outside the bounds of the group.94 It is not uncommon for
individuals to develop prejudice against groups to which they cannot belong. It is
therefore not surprising that hostility often emerges against members of ethnic or racial
groups to which entry for outsiders may be impossible. The implication for international
conflict is apparent: intergroup hostility may dissolve in the face of some urgently felt
worldwide crisis that only supranational cooperation can avert: atmospheric pollution or
an international AIDS epidemic, for example. These principles also have implications for
clinical work with small groups.
Intermember conflict during the course of group therapy must be contained. Above all,
communication must not be ruptured, and the adversaries must continue to work together
in a meaningful way, to take responsibility for their statements, and to be willing to go
beyond namecalling. This is, of course, a major difference between therapy groups and
social groups, in which conflicts often result in the permanent rupture of relationships.
Clients’ descriptions of critical incidents in therapy (see chapter 2) often involve an
episode in which they expressed strong negative affect. In each instance, however, the
client was able to weather the storm and to continue relating (often in a more gratifying
manner) to the other member.
Underlying these events is the condition of cohesiveness. The group and the members
must mean enough to each other to be willing to bear the discomfort of working through a
conflict. Cohesive groups are, in a sense, like families with much internecine warfare but a
powerful sense of loyalty.
Several studies demonstrate that cohesiveness is positively correlated with risk taking
and intensive interaction.95 Thus, cohesiveness is not synonymous with love or with a
continuous stream of supportive, positive statements. Cohesive groups are groups that are
able to embrace conflict and to derive constructive benefit from it. Obviously, in times of
conflict, cohesiveness scales that emphasize warmth, comfort, and support will
temporarily gyrate; thus, many researchers have reservations about viewing cohesiveness
as a precise, stable, measurable, unidimensional variable and consider it instead as
multidimensional.96

Once the group is able to deal constructively with conflict in the group, therapy is
enhanced in many ways. I have already mentioned the importance of catharsis, of risk
taking, of gradually exploring previously avoided or unknown parts of oneself and
recognizing that the anticipated dreaded catastrophe is chimerical. Many clients are
desperately afraid of anger—their own and that of others. A highly cohesive group
encourages members to tolerate the pain and hurt that interpersonal learning may produce.
But keep in mind that it is the early engagement that makes such successful working-
through later possible.97 The premature expression of excess hostility before group
cohesion has been established is a leading cause of group fragmentation. It is important for
clients to realize that their anger is not lethal. Both they and others can and do survive an
expression of their impatience, irritability, and even outright rage. For some clients, it is
also important to have the experience of weathering an attack. In the process, they may
become better acquainted with the reasons for their position and learn to withstand
pressure from others.98
Conflict may also enhance self-disclosure, as each opponent tends to reveal more and
more to clarify his or her position. As members are able to go beyond the mere statement
of position, as they begin to understand the other’s experiential world, past and present,
and view the other’s position from their own frame of reference, they may begin to
understand that the other’s point of view may be as appropriate for that person as their
own is for themselves. The working through of extreme dislike or hatred of another person
is an experience of great therapeutic power. A clinical illustration demonstrates many of
these points (another example may be found in my novel The Schopenhauer Cure).99
• 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 lifestyle, and what she imagined to be her
sloth and promiscuity. Jean was enraged by Susan’s judgmentalism, her
sanctimoniousness, her embittered spinsterhood, 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. Just at that
time Susan became a member and, during Jean’s absence, became heavily involved
in the group.)
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 realized the cruelty of their mutual judgmentalism. Finally, they could
both understand how much each meant for the other on both a personal and a
symbolic level. Jean desperately wanted Susan’s approval; Susan deeply envied

Jean for the freedom she had never permitted herself. In the working-through
process, both fully experienced their rage; they 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.
Not only are cohesive groups more able to express hostility among members but there is
evidence that they are also more able to express hostility toward the leader.100 Regardless
of the personal style or skill of group leaders, the therapy group will nonetheless come,
often within the first dozen meetings, to experience some degree of hostility and
resentment toward them. (See chapter 11 for a full discussion of this issue.) Leaders do not
fulfill members’ fantasized expectations and, in the view of many members, do not care
enough, do not direct enough, and do not offer immediate relief. If the group members
suppress these feelings of disappointment or anger, several harmful consequences may
ensue. They may attack a convenient scapegoat—another member or some institution like
“psychiatry” or “doctors.” They may experience a smoldering irritation within themselves
or within the group as a whole. They may, in short, begin to establish norms discouraging
open expression of feelings. The presence of such scapegoating may be a signal that
aggression is being displaced away from its more rightful source—often the therapist.101
Leaders who challenge rather than collude with group scapegoating not only safeguard
against an unfair attack, they also demonstrate their commitment to authenticity and
responsibility in relationships.
The group that is able to express negative feelings toward the therapist almost
invariably is strengthened by the experience. It is an excellent exercise in direct
communication and provides an important learning experience—namely, that one may
express hostility directly without some ensuing irreparable calamity. It is far preferable
that the therapist, the true object of the anger, be confronted than for the anger to be
displaced onto some other member in the group. Furthermore, the therapist, let us pray, is
far better able than a scapegoated member to withstand confrontation. The entire process
is self-reinforcing; a concerted attack on the leader that is handled in a nondefensive,
nonretaliatory fashion serves to increase cohesiveness still further.
One cautionary note about cohesion: misguided ideas about cohesion may interfere with
the group task.102 Janis coined the term “groupthink” to describe the phenomenon of
“deterioration of mental efficiency, reality testing, and moral judgment that results from
group pressure.”103 Group pressure to conform and maintain consensus may create a
groupthink environment. This is not an alliance-based cohesion that facilitates the growth
of the group members; on the contrary, it is a misalliance based on naive or regressive
assumptions about belonging. Critical and analytic thought by the group members needs to
be endorsed and encouraged by the group leader as an essential group norm.104
Autocratic, closed and authoritarian leaders discourage such thought. Their groups are
more prone to resist uncertainty, to be less reflective, and to close down exploration
prematurely.105

Group Cohesiveness and Other Therapy-Relevant Variables
Research from both therapy and laboratory groups has demonstrated that group
cohesiveness has a plethora of important consequences that have obvious relevance to the
group therapeutic process.106 It has been shown, for example, that the members of a
cohesive group, in contrast to the members of a noncohesive group, will:
1. Try harder to influence other group members 107
2. Be more open to influence by the other members108
3. Be more willing to listen to others109 and more accepting of others110
4. Experience greater security and relief from tension in the group111
5. Participate more readily in meetings112
6. Self-disclose more113
7. Protect the group norms and exert more pressure on individuals deviating from the
norms114
8. Be less susceptible to disruption as a group when a member terminates
membership115
9. Experience greater ownership of the group therapy enterprise116
SUMMARY
By definition, cohesiveness refers to the attraction that members have for their group and
for the other members. It is experienced at interpersonal, intrapersonal, and intragroup
levels. The members of a cohesive group are accepting of one another, supportive, and
inclined to form meaningful relationships in the group. Cohesiveness is a significant factor
in successful group therapy outcome. In conditions of acceptance and understanding,
members will be more inclined to express and explore themselves, to become aware of
and integrate hitherto unacceptable aspects of self, and to relate more deeply to others.
Self-esteem is greatly influenced by the client’s role in a cohesive group. The social
behavior required for members to be esteemed by the group is socially adaptive to the
individual out of the group.
In addition, highly cohesive groups are more stable groups, with better attendance and
less turnover. Evidence was presented to indicate that this stability is vital to successful
therapy: early termination precludes benefit for the involved client and impedes the
progress of the rest of the group as well. Cohesiveness favors self-disclosure, risk taking,
and the constructive expression of conflict in the group—phenomenon that facilitate
successful therapy.

What we have yet to consider are the determinants of cohesiveness. What are the
sources of high and low cohesiveness? What does the therapist do to facilitate the
development of a highly cohesive group? These important issues will be discussed in the
chapters dealing with the group therapist’s tasks and techniques.

Chapter 4
THE THERAPEUTIC FACTORS: AN INTEGRATION
We began our inquiry into the group therapy therapeutic factors with the rationale that the
delineation of these factors would guide us to a formulation of effective tactics and
strategies for the therapist. The compendium of therapeutic factors presented in chapter 1
is, I believe, comprehensive but is not yet in a form that has great clinical applicability.
For the sake of clarity I have considered the factors as separate entities, whereas in fact
they are intricately interdependent. In other words, I have taken the therapy process apart
to examine it, and now it is time to put it back together again.
In this chapter I first consider how the therapeutic factors operate when they are viewed
not separately but as part of a dynamic process. Next I address the comparative potency of
the therapeutic factors. Obviously, they are not all of equal value. However, an absolute
rank-ordering of therapeutic factors is not possible. Many contingencies must be
considered. The importance of various therapeutic factors depends on the type of group
therapy practiced. Groups differ in their clinical populations, therapeutic goals, and
treatment settings—for example, eating disorders groups, panic disorder groups, substance
abuse groups, medical illness groups, ongoing outpatient groups, brief therapy groups,
inpatient groups, and partial hospitalization groups. They may emphasize different clusters
of therapeutic factors, and some therapeutic factors are important at one stage of a group,
whereas others predominate at another. Even within the same group, different clients
benefit from different therapeutic factors. Like diners at a cafeteria, group members will
choose their personalized menu of therapeutic factors, depending on such factors as their
needs, their social skills, and their character structure.
This chapter underscores the point that some factors are not always independent
mechanisms of change but instead create the conditions for change. For example, as I
mentioned in chapter 1, instillation of hope may serve largely to prevent early
discouragement and to keep members in the group until other, more potent 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 other members, cohesiveness is important because it provides the
conditions, 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 twenty-five years there has been a groundswell of
research on the therapeutic factors: recent reviews have cited hundreds of studies.1 Yet
little definitive research has been conducted on the comparative value of the therapeutic
factors and their interrelation; indeed, we may never attain a high degree of certainty as to
these comparative values. We have summaries at the end of sections for those readers less
interested in research detail.
I do not speak from a position of investigative nihilism but instead argue that the nature

of our data on therapeutic factors is so highly subjective that it largely resists the
application of scientific methodology. The precision of our instrumentation and statistical
analysis will always be limited by the imprecision of our primary data—the clients’
assessment of what was most helpful about their group therapy experience. We may
improve our data collection by asking our clients these questions at repeated intervals or
by having independent raters evaluate the therapeutic factors at work,2 but we are still left
trying to quantify and categorize subjective dimensions that do not fit easily into an
objective and categorical system.†3 We must also recognize limits in our ability to infer
objective therapeutic cause and effect accurately from rater observation or client
reflection, both of which are inherently subjective. This point is best appreciated by those
therapists and researchers who themselves have had a personal therapy experience. They
need only pose themselves the task of evaluating and rating the therapeutic factors in their
own therapy to realize that precise judgment can never be attained. 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
paid poorly 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 avoid a negative cascade of depressive thoughts and self-derogation
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 that she had desperately needed to talk
and arrived early for the meeting, saw no one else and assumed not only that the
group had been canceled but also that the leader had uncaringly failed to notify
her. She was angrily contemplating leaving, when the group members arrived. As
she talked, she smiled knowingly, acknowledging the depressive assumptions she
continually makes and her propensity to act upon them.
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.” At age
eight she had a diagnostic workup for tuberculosis because of a positive 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 to
receive this kind feedback and reassurance instead.”
We can see in this illustration the presence of the several therapeutic factors—
universality, instillation of hope, self-understanding, imparting information, family
reenactment, interpersonal learning, and catharsis. Which therapeutic factor is primary?
How can we determine that with any certainty?

Some attempts have been made to use subjectively evaluated therapeutic factors as
independent variables in outcome studies. Yet enormous difficulties are encountered in
such research. The methodological problems are formidable: as a general rule, the
accuracy with which variables can be measured is directly proportional to their triviality.
A comprehensive review of such empirical studies produced only a handful of studies that
had an acceptable research design, and these studies have limited clinical relevance. 4 For
example, four studies attempted to quantify and evaluate insight by comparing insight
groups with other approaches, such as assertiveness training groups or interactional here-
and-now groups (as though such interactional groups offered no insight).5 The researchers
measured insight by counting the number of a therapist’s insight-providing comments or
by observers’ ratings of a leader’s insight orientation. Such a design fails to take into
account the crucial aspects of the experience of insight: for example, how accurate was the
insight? How well timed? Was the client in a state of readiness to accept it? What was the
nature of the client’s relationship with the therapist? (If adversarial, the client is apt to
reject any interpretation; if dependent, the client may ingest all interpretations without
discrimination.) Insight is a deeply subjective experience that cannot be rated by objective
measures (one accurate, well-timed interpretation is worth a score of interpretations that
fail to hit home). Perhaps it is for these reasons that no new research on insight in group
therapy and outcome has been reported in the past decade. In virtually every form of
psychotherapy the therapist must appreciate the full context of the therapy to understand
the nature of effective therapeutic interventions.6
As a result, I fear that empirical psychotherapy research will never provide the certainty
we crave, and we must learn to live effectively with uncertainty. We must listen to what
clients tell us and consider the best available evidence from research and intelligent
clinical observation. Ultimately we must evolve a reasoned therapy that offers the great
flexibility needed to cope with the infinite range of human problems.
COMPARATIVE VALUE OF THE THERAPEUTIC
FACTORS: THE CLIENT’S VIEW
How do group members evaluate the various therapeutic factors? Which factors do they
regard as most salient to their improvement in therapy? In the first two editions of this
book, it was possible to review in a leisurely fashion the small body of research bearing on
this question: I discussed the two existing studies that explicitly explored the client’s
subjective appraisal of the therapeutic factors, and then proceeded to describe in detail the
results of my first therapeutic factor research project.7 For that undertaking, my colleagues
and I administered to twenty successful group therapy participants a therapeutic factor
questionnaire designed to compare the importance of the eleven therapeutic factors I
identified in chapter 1.
Things have changed since then. In the past four decades, a deluge of studies have

researched the client’s view of the therapeutic factors (several of these studies have also
obtained therapists’ ratings of therapeutic factors). Recent research demonstrates that a
focus on therapeutic factors is a very useful way for therapists to shape their group
therapeutic strategies to match their clients’ goals.8 This burst of research provides rich
data and enables us to draw conclusions with far more conviction about therapeutic
factors. For one thing, it is clear that the differential value of the therapeutic factors is
vastly influenced by the type of group, the stage of the therapy, and the intellectual level
of the client. Thus, the overall task of reviewing and synthesizing the literature is far more
difficult.
However, since most of the researchers use some modification of the therapeutic factors
and the research instrument I described in my 1970 research, 9 I will describe that research
in detail and then incorporate into my discussion the findings from more recent research
on therapeutic factors.10
My colleagues and I studied the therapeutic factors in twenty successful long-term
group therapy clients. 11 We asked twenty group therapists to select their most successful
client. These therapists led groups of middle-class outpatients who had neurotic or
characterological problems. The subjects had been in therapy eight to twenty-two months
(the mean duration was sixteen months) and had recently terminated or were about to
terminate group therapy.12 All subjects completed a therapeutic factor Q-sort and were
interviewed by the investigators.
Twelve categories of therapeutic factors were constructed from the sources outlined
throughout this book,13f and five items describing each category were written, making a
total of sixty items (see table 4.1). Each item was typed on a 3 × 5 card; the client was
given the stack of randomly arranged cards and asked to place a specified number of cards
into seven piles labeled as follows:
Most helpful to me in the group (2 cards)
Extremely helpful (6 cards)
Very helpful (12 cards)
Helpful (20 cards)
Barely helpful (12 cards)
Less helpful (6 cards)
Least helpful to me in the group (2 cards)14
TABLE 4.1 Therapeutic Factors: Categories and Rankings of the Sixty Individual Items

After the Q-sort, which took thirty to forty-five minutes, each subject was interviewed
for an hour by the three investigators. Their reasons for their choice of the most and least
helpful items were reviewed, and a series of other areas relevant to therapeutic factors was
discussed (for example, other, nonprofessional therapeutic influences in the clients’ lives,
critical events in therapy, goal changes, timing of improvement, therapeutic factors in their
own words).
Results
A sixty-item, seven-pile Q-sort for twenty subjects makes for complex data. Perhaps the
clearest way to consider the results is a simple rank-ordering of the sixty items (arrived at
by ranking the sum of the twenty pile placements for each item). Turn again to table 4.1.
The number after each item represents its rank order. Thus, on average, item 48
(Discovering and accepting previously unknown or unacceptable parts of myself) was
considered the most important therapeutic factor by the subjects, item 38 (Adopting
mannerisms or the style of another group member) the least important, and so on.
The ten items the subjects deemed most helpful were, in order of importance:

1. Discovering and accepting previously unknown or unacceptable parts of myself.
2. Being able to say what was bothering me instead of holding it in.
3. Other members honestly telling me what they think of me.
4. Learning how to express my feelings.
5. The group’s teaching me about the type of impression I make on others.
6. Expressing negative and/or positive feelings toward another member.
7. Learning that I must take ultimate responsibility for the way I live my life no
matter how much guidance and support I get from others.
8. Learning how I come across to others.
9. Seeing that others could reveal embarrassing things and take other risks and
benefit from it helped me to do the same.
10. Feeling more trustful of groups and of other people.
Note that seven of the first eight items represent some form of catharsis or of insight. I
again use insight in the broadest sense; the items, for the most part, reflect the first level of
insight (gaining an objective perspective of one’s interpersonal behavior) described in
chapter 2. This remarkable finding lends considerable weight to the principle, also
described in chapter 2, that therapy is a dual process consisting of emotional experience
and of reflection on that experience. More, much more, about this later.
The administration and scoring of a sixty-item Q-sort is so laborious that most
researchers have since used an abbreviated version—generally, one that asks a subject to
rank the twelve therapeutic factor categories rather than sixty individual items. However,
four studies that replicate the sixty-item Q-sort study report remarkably similar findings.15
If we analyze the twelve general categories,g we find the following rank order of
importance:
1. Interpersonal input
2. Catharsis
3. Cohesiveness
4. Self-understanding
5. Interpersonal output
6. Existential factors
7. Universality
8. Instillation of hope
9. Altruism
10. Family reenactment

11. Guidance
12. Identificationh
A number of other replicating studies describe the therapeutic factors selected by group
therapy outpatients.16 These studies are in considerable agreement: the most commonly
chosen therapeutic factors are catharsis, self-understanding, and interpersonal input,
closely followed by cohesiveness and universality. The same trio of most helpful
therapeutic factors (interpersonal input, self-understanding, and catharsis) has been
reported in studies of personal growth groups.17 One researcher suggests that the
therapeutic factors fall into three main clusters: the remoralization factor (cluster of hope,
universality, and acceptance), the self-revelation factor (self-disclosure and catharsis), and
the specific psychological work factor (interpersonal learning and self-understanding).18
This clustering resembles a factor analysisi of therapeutic factors collected from studies of
American Group Psychotherapy Association Institute experiential groups suggesting that
the group therapeutic factors fall into three main categories: early factors of belonging and
remoralization common to all therapy groups; factors of guidance and instruction; and
specific skill development factors. Despite different terminology, both of these clustering
approaches suggest that the group therapeutic factors consist of universal mechanisms,
mediating mechanisms, and specific change mechanisms.19
Which therapeutic factors are least valued? All of the studies of therapy groups and
personal growth groups report the same results: family reenactment, guidance, and
identification. These results all suggest that the defining core of the therapeutic process in
these therapy groups is an affectively charged, self-reflective interpersonal interaction, in a
supportive and trusting setting.20 Comparisons of individual and group therapy therapeutic
factors consistently underscore this finding21 and support the importance of the basic
concepts I discussed in chapter 2—the importance of the corrective emotional experience
and the concept that the therapeutic here-and-now focus consists of an experiencing and a
cognitive component.

In the following sections, I will incorporate these research findings in a broader discussion
of the questions posed at the beginning of this chapter on the interrelationships and
comparative potency of the therapeutic factors. Keep in mind throughout that these
findings pertain to a specific type of therapy group: an interactionally based group with
the ambitious goals of symptom relief and behavioral and characterological change. Later
in this chapter I will present some evidence that other groups with different goals and
shorter duration may capitalize on different clusters of therapeutic factors.
Catharsis
Catharsis has always assumed an important role in the therapeutic process, though the

rationale behind its use has undergone a metamorphosis. For centuries, sufferers have been
purged to be cleansed of excessive bile, evil spirits, and infectious toxins (the word itself
is derived from the Greek “to clean”). Since Breuer and Freud’s 1895 treatise on the
treatment of hysteria,22 many therapists have attempted to help clients rid themselves of
suppressed, choked affect. What Freud and subsequently all dynamic psychotherapists
have learned is that catharsis is not enough. After all, we have emotional discharges,
sometimes very intense ones, all our lives without their leading to change.
The data support this conclusion. Although studies of clients’ appraisals of the
therapeutic factors reveals the importance of catharsis, the research also suggests
important qualifications. The Lieberman, Yalom, and Miles study starkly illustrates the
limitations of catharsis per se.23 The authors asked 210 members of a thirty-hour
encounter group to describe the most significant incident that occurred in the course of the
group. Experiencing and expressing feelings (both positive and negative) was cited
frequently. Yet this critical incident was not related to positive outcome: incidents of
catharsis were as likely to be selected by members with poor outcomes as by those with
good outcomes. Catharsis was not unrelated to outcome; it was necessary but in itself not
sufficient. Indeed, members who cited only catharsis were somewhat more likely to have
had a negative experience in the group. The high learners characteristically showed a
profile of catharsis plus some form of cognitive learning. The ability to reflect on one’s
emotional experience is an essential component of the change process.†
In the Q-sort therapeutic factor studies, the two items that are ranked most highly and
are most characteristic of the catharsis category in factor analytic studies are items 34
(Learning how to express my feelings) and 35 (Being able to say what was bothering me).
Both of these items convey something other than the sheer act of ventilation or abreaction.
They connote a sense of liberation and acquiring skills for the future. The other frequently
chosen catharsis item—item 32 (Expressing negative and/or positive feelings toward
another member)—indicates the role of catharsis in the ongoing interpersonal process.
Item 31, which most conveys the purest sense of sheer ventilation (Getting things off my
chest), was not highly ranked by group members.24
Interviews with the clients to investigate the reasons for their selection of items
confirmed this view. Catharsis was viewed as part of an interpersonal process; no one
ever obtains enduring benefit from ventilating feelings in an empty closet. Furthermore, as
I discussed in chapter 3, catharsis is intricately related to cohesiveness. Catharsis is more
helpful once supportive group bonds have formed; in other words, catharsis is more
valued late rather than early in the course of the group.25 Conversely, strong expression of
emotion enhances the development of cohesiveness: members who express strong feelings
toward one another and work honestly with these feelings will develop close mutual
bonds. In groups of clients dealing with loss, researchers found that expression of positive
affect was associated with positive outcomes. The expression of negative affect, on the
other hand, was therapeutic only when it occurred in the context of genuine attempts to
understand oneself or other group members.26
Emotional expression is directly linked with hope and a sense of personal effectiveness.

Emotional disclosure is also linked to the ability to cope: articulation of one’s needs
permits oneself and the people in one’s environment to respond productively to life’s
challenges. Women with early breast cancer who are emotionally expressive achieve a
much better quality of life than those who avoid and suppress their distress.27 Recently
bereaved HIV-positive men who are able to express emotions, grieve, and find meaning in
their losses, maintain significantly higher immune function and live longer than those who
minimize their distress and avoid the mourning process.28
In summary, then, the open expression of affect is vital to the group therapeutic process;
in its absence, a group would degenerate into a sterile academic exercise. Yet it is only
part of the process and must be complemented by other factors. One last point: the
intensity of emotional expression is highly relative and must be appreciated not from the
leader’s perspective but from that of each member’s experiential world. A seemingly
muted expression of emotion may, for a highly constricted individual, represent an event
of considerable intensity. On many occasions I have heard students view a videotape of a
group meeting and describe the session as muted and boring, whereas the members
themselves experienced the session as intense and highly charged.
Self-Understanding
The therapeutic factor Q-sort also underscores the important role that the intellectual
component plays in the therapeutic process. Of the twelve categories, the two pertaining to
the intellectual task in therapy (interpersonal input and self-understanding) are both ranked
highly. Interpersonal input, discussed at some length in chapter 2, refers to the
individual’s learning how he or she is perceived by other people. It is the crucial first step
in the therapeutic sequence of the therapeutic factor of interpersonal learning.
The category of self-understanding is more problematic. It was constructed to permit
investigation of the importance of derepression and of the intellectual understanding of the
relationship between past and present (genetic insight). Refer back to table 4.1 and
examine the five items of the “self-understanding” category. It is clear that the category is
an inconsistent one, containing several very different elements. There is poor correlation
among items, some being highly valued by group therapy members and some less so. Item
48, Discovering and accepting previously unknown or unacceptable parts of myself, is the
single most valued item of all the sixty. Two items (46 and 47) that refer to understanding
causes of problems and to recognizing the existence of interpersonal distortion are also
highly valued. The item that most explicitly refers to genetic insight, item 50, is
considered of little value by group therapy clients.
This finding has been corroborated by other researchers. One study replicated the
therapeutic factor Q-sort study and, on the basis of a factor analysis, subdivided insight
into two categories: self-understanding and genetic insight. The sample of seventy-two
group therapy members ranked self-understanding fourth of fourteen factors and genetic
insight eighth.29 Another study concluded that genetic interpretations were significantly
less effective than here-and-now feedback in producing positive group therapy outcomes.

In fact, clients not only showed little benefit from genetic interpretations but in particular
considered the leaders’ efforts in this regard unproductive. Comembers were more
effective: their efforts at linking present to past contained less jargon and were linked
more directly to actual experience than were the therapists’ more conceptual, less “real”
explanations.30
When we interviewed the subjects in our study to learn more about the meaning of their
choices, we found that the most popular item—48, Discovering and accepting previously
unknown or unacceptable parts of myself —had a very specific implication to group
members. More often than not, they discovered positive areas of themselves: the ability to
care for another, to relate closely to others, to experience compassion.
There is an important lesson to be learned here. Too often psychotherapy, especially in
naive, popularized, or early conceptualizations, is viewed as a detective search, as a
digging or a stripping away. Rogers, Horney, Maslow, and our clients as well remind us
that therapy is also horizontal and upward exploration; digging or excavation may uncover
our riches and treasures as well as shameful, fearful, or primitive aspects of ourselves.31
Our clients want to be liberated from pathogenic beliefs; they seek personal growth and
control over their lives. As they gain fuller access to themselves, they become emboldened
and increase their sense of ownership of their personhood. Psychotherapy has grown
beyond its emphasis on eradicating the “pathological” and now aims at increasing clients’
breadth of positive emotions and cognitions. A group therapy approach that encourages
members to create and inhabit a powerful and caring environment is a potent approach to
these contemporary goals.†32
Thus, one way that self-understanding promotes change is by encouraging individuals
to recognize, integrate, and give free expression to previously obscured parts of
themselves. When we deny or stifle parts of ourselves, we pay a heavy price: we feel a
deep, amorphous sense of restriction; we are constantly on guard; we are often troubled
and puzzled by internal but seemingly alien impulses that demand expression. When we
are able to reclaim these disavowed parts, we experience a wholeness, and a sense of
liberation.
So far, so good. But what of the other components of the intellectual task? For example,
how does the highly ranked item Learning why I think and feel the way I do (item 47)
result in therapeutic change?
First, we must recognize that there is an urgent need for intellectual understanding in
the psychotherapeutic enterprise, a need that comes from both client and therapist. Our
search for understanding is deeply rooted. Maslow, in a treatise on motivation, suggested
that the human being has cognitive needs that are as basic as the needs for safety, love, and
self-esteem. 33 Most children are exceedingly curious; in fact, we grow concerned if a
child lacks curiosity about the environment. Researchers studying primates also see high
levels of curiosity: monkeys in a solid enclosure will do considerable work for the
privilege of being able to look through a window to see outside; they will also work hard
and persistently to solve puzzles without any reward except the satisfactions inherent in
the puzzle solving.

In an analogous fashion our clients automatically search for understanding, and
therapists who prize the intellectual pursuit join them. Often, it all seems so natural that
we lose sight of the raison d’être of therapy. After all, the object of therapy is change, not
self-understanding. Or is it? Are the two synonymous? Does any and every type of self-
understanding lead automatically to change? Or is the quest for self-understanding simply
an interesting, appealing, reasonable exercise for clients and therapists, serving, like
mortar, to keep the two joined together while something else—“relationship”—develops.
Perhaps it is relationship that is the real mutative force in therapy. In fact, there is
considerable evidence that a supportive psychotherapy relationship in a noninterpretive
therapy can produce substantial change in interpersonal behavior.34 It is far easier to pose
these questions than to answer them. I will present some preliminary points here, and in
chapter 6, after developing some material on the interpretative task and techniques of the
therapist, I will attempt to present a coherent thesis.
If we examine the motives behind our curiosity and our proclivity to explore our
environment, we shed some light on the process of change. These motives include
effectance (our desire for mastery and power), safety (our desire to render the unexplained
harmless through understanding), and pure cognizance (our desire for knowledge and
exploration for its own sake).35 The worried householder who explores a mysterious and
frightening noise in his home; the young student who, for the first time, looks through a
microscope and experiences the exhilaration of understanding the structure of an insect
wing; the medieval alchemist or the New World explorer probing uncharted and
proscribed regions—all receive their respective rewards: safety, a sense of personal
keenness and satisfaction, and mastery in the guise of knowledge or wealth.
Of these motives, the one least relevant for the change process is pure cognizance.
There is little question that knowledge for its own sake has always propelled the human
being. The lure of the forbidden is an extraordinarily popular and ubiquitous motif in folk
literature, from the story of Adam and Eve to the saga of Peeping Tom. It is no surprise,
then, that the desire to know enters the psychotherapeutic arena. Yet there is little evidence
that understanding for its own sake results in change.
But the desires for safety and for mastery play an important and obvious role in
psychotherapy. They are, of course, as White has ably discussed, closely intertwined.36
The unexplained—especially the frightening unexplained—cannot be tolerated for long.
All cultures, through either a scientific or a religious explanation, attempt to make sense of
chaotic and threatening situations in the physical and social environment as well as in the
nature of existence itself. One of our chief methods of control is through language. Giving
a name to chaotic, unruly forces provides us with a sense of mastery or control. In the
psychotherapeutic situation, information decreases anxiety by removing ambiguity. There
is considerable research evidence supporting this observation.37
The converse is, incidentally, also true: anxiety increases ambiguity by distorting
perceptual acuteness. Anxious subjects show disturbed organization of visual perception;
they are less capable of perceiving and organizing rapid visual cues and are distinctly
slower in completing and recognizing incomplete pictures in a controlled experimental

setting.38 Unless one is able to order the world cognitively, one may experience anxiety,
which, if severe, interferes with the perceptual apparatus. Thus, anxiety begets anxiety: the
ensuing perplexity and overt or subliminal awareness of perceptual distortion become a
potent secondary source of anxiety.39
In psychotherapy, clients are enormously reassured by the belief that their chaotic inner
world, their suffering, and their tortuous interpersonal relationships are all explicable and
thereby governable. Maslow, in fact, views the increase of knowledge as having
transformative effects far beyond the realms of safety, anxiety reduction, and mastery. He
views psychiatric illness as a disease caused by knowledge deficiency.40 In this way he
would support the moral philosophic contention that if we know the good, we will always
act for the good. Presumably it follows that if we know what is ultimately good for us we
will act in our own best interests.41j
Therapists, too, are less anxious if, when confronted with great suffering and
voluminous, chaotic material, they can believe in a set of principles that will permit an
ordered explanation. Frequently, therapists will cling tenaciously to a particular system in
the face of considerable contradictory evidence—sometimes, in the case of researcher-
clinicians, even evidence that has issued from their own investigations. Though such
tenacity of belief may carry many disadvantages, it performs one valuable function: it
enables the therapist to preserve equanimity in the face of considerable affect emerging
within the transference or countertransference.
There is little in the above that is controversial. Self-knowledge permits us to integrate
all parts of ourselves, decreases ambiguity, permits a sense of effectance and mastery, and
allows us to act in concert with our own best interests. An explanatory scheme also
permits generalization and transfer of learning from the therapy setting to new situations
in the outside world.
The great controversies arise when we discuss not the process or the purpose or the
effects of explanation but the content of explanation. As I hope to make clear in chapter 6,
I think these controversies are irrelevant. When we focus on change rather than on self-
understanding as our ultimate goal, we can only conclude that an explanation is correct if
it leads to change. The final common result of all our intellectual efforts in therapy is
change. Each clarifying, explanatory, or interpretive act of the therapist is ultimately
designed to exert leverage on the client’s will to change.
Imitative Behavior (Identification)
Group therapy participants rate imitative behavior among the least helpful of the twelve
therapeutic factors. However, we learned from debriefing interviews that the five items in
this category seem to have tapped only a limited sector of this therapeutic mode (see table
4.1). They failed to distinguish between mere mimicry, which apparently has only a
restricted value for clients, and the acquisition of general styles and strategies of behavior,
which may have considerable value. To clients, conscious mimicry is an especially

unpopular concept as a therapeutic mode since it suggests a relinquishing of individuality
—a basic fear of many group participants.
On the other hand, clients may acquire from others a general strategy that may be used
across a variety of personal situations. Members of groups for medically ill patients often
benefit from seeing other members manage a shared problem effectively.42 This process
also works at both overt and more subtle levels. Clients may begin to approach problems
by considering, consciously or unconsciously, what some other member or the therapist
would think or do in the same situation. If the therapist is tolerant and flexible, then clients
may also adopt these traits. If the therapist is self-disclosing and accepts limitations
without becoming insecure or defensive, then clients are more apt to learn to accept their
personal shortcomings.43 Not only do group members adopt the traits and style of the
therapist, but sometimes they may even assimilate the therapist’s complex value system.44
Initially, imitative behavior is in part an attempt to gain approval, but it does not end
there. The more intact clients retain their reality testing and flexibility and soon realize
that changes in their behavior result in greater acceptance by others. This increased
acceptance can then act to change one’s self-concept and self-esteem in the manner
described in chapter 3, and an adaptive spiral is instigated. It is also possible for an
individual to identify with aspects of two or more other people, resulting in an amalgam.
Although parts of others are imitated, the amalgam represents a creative synthesis, a
highly innovative individualistic identity.
What of spectator therapy? Is it possible that clients may learn much from observing the
solutions arrived at by others who have similar problems? I have no doubt that such
learning occurs in the therapy group. Every experienced group therapist has at least one
story of a member who came regularly to the group for months on end, was extremely
inactive, and finally terminated therapy much improved.
I clearly remember Rod, who was so shy, isolated, and socially phobic that in his adult
life he had never shared a meal with another person. When I introduced him into a rather
fast-paced group, I was concerned that he would be in over his head. And in a sense he
was. For months he sat and listened in silent amazement as the other members interacted
intensively with one another. That was a period of high learning for Rod: simply to be
exposed to the possibilities of intimate interaction enriched his life. But then things
changed! The group began to demand more reciprocity and placed great pressure on him
to participate more personally in the meetings. Rod grew more uncomfortable and
ultimately, with my encouragement, decided to leave the group. Since he worked at the
same university, I had occasion to cross paths with him several times in the ensuing years,
and he never failed to inform me how important and personally useful the group had been.
It had shown him what was possible and how individuals could engage one another, and it
offered him an internal reference point to which he could turn for reassurance as he
gradually reached out to touch others in his life.
Clients learn not only from observing the substantive work of others who are like them
but also from watching the process of the work. In that sense, imitative behavior is a
transitional therapeutic factor that permits clients subsequently to engage more fully in

other aspects of therapy. Proof of this is to be found in the fact that one of the five
imitative behavior items (item 37, Seeing that others could reveal embarrassing things
and take other risks and benefit from it helped me to do the same) was rated as the eighth
(of sixty) most important therapeutic factor. A largescale study in the Netherlands found
that clients considered identification to be more important in the early stages of therapy,
when novice members looked for more senior members with whom to identify.45
Family Reenactment
Family reenactment, or the corrective recapitulation of the primary family experience—a
therapeutic factor highly valued by many therapists—is not generally considered helpful
by most group members. The clinical populations that place a high value on this factor are
very specific—groups for incest survivors46 and groups for sex offenders.47 For these
members the early failure of the family to protect and care for them looms as a powerful
issue.
The fact that this factor is not cited often by most group members, though, should not
surprise us, since it operates at a different level of awareness from such explicit factors as
catharsis or universality. Family reenactment becomes more a part of the general horizon
against which the group is experienced. Few therapists will deny that the primary family
of each group member is an omnipresent specter haunting the group therapy room.
Clients’ experience in their family of origin obviously will, to a great degree, influence the
nature of their interpersonal distortions, the role they assume in the group, and their
attitudes toward the group leaders.
There is little doubt in my mind that the therapy group reincarnates the primary family.
It acts as a time machine, flinging the client back several decades and evoking deeply
etched ancient memories and feelings. In fact, this phenomenon is one of the major
sources of power of the therapy group. In my last meeting with a group before departing
for a year’s sabbatical, a client related the following dream: “My father was going away
for a long trip. I was with a group of people. My father left us a thirtyfoot boat, but rather
than giving it to me to steer, he gave it to one of my friends, and I was angry about this.”
This is not the place to discuss this dream fully. Suffice it to say that the client’s father had
deserted the family when the client was young and left him to be tyrannized thereafter by
an older brother. The client said that this was the first time he had thought of his father in
years. The events of the group—my departure, my place being taken by a new therapist,
the client’s attraction to the co-therapist (a woman), his resentment toward another
dominating member in the group—all acted in concert to awaken long-slumbering
memories. Clients reenact early family scripts in the group and, in successful group
therapy, experiment with new behavior and break free from the rigid family roles into
which they had long been locked.
While I believe these are important phenomena in the therapeutic process, it is
altogether a different question whether the group should focus explicitly on them. I think
not, as this process is part of the internal, generally silent, homework of the group

member. Major shifts in our perspective on the past occur because of the vitality of the
work in the present—not through a direct summons and inquiry of the spirits of the past.
There are, as I will discuss in chapter 6, many overriding reasons for the group to maintain
an ahistorical focus. To focus unduly on people who are not present, on parents and
siblings, on Oedipal strivings, on sibling rivalries, or patricidal desires is to avoid and
deny the reality of the group and the other members as a living experience in the here-and-
now.
Existential Factors
The category of existential factors was almost an afterthought. My colleagues and I first
constructed the Q-sort instrument with eleven major factors. It appeared neat and precise,
but something was missing. Important sentiments expressed by both clients and therapists
had not been represented, so we added a factor consisting of these five items:
1. Recognizing that life is at times unfair and unjust
2. Recognizing that ultimately there is no escape from some of life’s pain or from
death
3. Recognizing that no matter how close I get to other people, I must still face life
alone
4. Facing the basic issues of my life and death, and thus living my life more honestly
and being less caught up in trivialities
5. Learning that I must take ultimate responsibility for the way I live my life no
matter how much guidance and support I get from others
Several issues are represented in this cluster: responsibility, basic isolation, contingency,
the capriciousness of existence, the recognition of our mortality and the ensuing
consequences for the conduct of our life. What to label this category? I finally settled, with
some hesitation, on existential factors, meaning that all these factors relate to existence—
to our confrontation with the human condition—a confrontation that informs us of the
harsh existential facts of life: our mortality, our freedom and responsibility for
constructing our own life design, our isolation from being thrown alone into existence, and
our search for life meaning despite being unfortunate enough to be thrown into a universe
without intrinsic meaning.
It is clear that the existential items strike responsive chords in clients, and many cite
some of the five items as having been crucially important to them. In fact, the entire
category of existential factors is often ranked highly, ahead of greatly valued modes of
change such as universality, altruism, recapitulation of the primary family experience,
guidance, identification, and instillation of hope. Item 60, Learning that I must take
ultimate responsibility for the way I live my life no matter how much guidance and support
I get from others, was ranked fifth overall of the sixty items.
The same findings are reported by other researchers. Every single project that includes

an existential category reports that subjects rank that category at least in the upper 50
percent. In some studies, for example, with therapy groups in prison, in day hospitals, in
psychiatric hospitals, and in alcohol treatment groups, the existential category is ranked
among the top three factors.48 Existential factors are also central to many of the current
group therapy interventions for the seriously medically ill.49 A group of older women
ranked existential factors first,50 as did a sample of sixty-six patients on an alcohol unit.51
What unites these divergent clinical populations is the participants’ awareness of
immutable limits in life—limits of time, power, or health. Even in groups led by therapists
who do not conceptualize existential factors as relevant, the existential factors are highly
valued by the group members.52
It is important to listen to our data. Obviously, the existential factors in therapy deserve
far more consideration than they generally receive. It is more than happenstance that the
category of existential factors was included almost as afterthought yet proved to be so
important to clients. Existential factors play an important but largely unrecognized role in
psychotherapy. There is no discrete school of existential psychotherapy, no single accepted
body of existential theory and techniques. Nonetheless, a considerable proportion of
American therapists (over 16 percent in a 1983 survey—as large a group as the
psychoanalytic contingent) consider themselves to be existentially or “existentially-
humanistically” oriented.53 A similar proportion of senior group therapists surveyed in
1992 endorsed the existential-humanistic approach as the model that best reflects
contemporary group therapy.54
Even therapists who nominally adhere to other orientations are often surprised when
they look deeply at their techniques and at their basic view of the human situation and find
that they are existentially oriented.55 Many psychoanalytically oriented therapists, for
example, inwardly eschew or at best ignore much of the classical analytic theory and
instead consider the authentic client-therapist encounter as the mutative element of
therapy.56
Keep in mind that classical psychoanalytic theory is based explicitly on a highly
materialistic view of human nature. It is not possible to understand Freud fully without
considering his allegiance to the Helmholtz school, an ideological school that dominated
Western European medical and basic research in the latter part of the nineteenth century.57
This doctrine holds that we human beings are precisely the sum of our parts. It is
deterministic, antivitalistic, and materialistic (that is, it attempts to explain the higher by
the lower).
Freud never swerved from his adherence to this postulate and to its implications about
human nature. Many of his more cumbersome formulations (for example, the dual-instinct
theory, the theory of libidinal energy conservation and transformation) were the result of
his unceasing attempts to fit human behavior to Helmholtzian rules. This approach
constitutes a negative definition of the existential approach. If you feel restricted by its
definition of yourself, if you feel that there’s something missing, that we are more than a
sum of parts, that the doctrine omits some of the central features that make us human—

such as purpose, responsibility, sentience, will, values, courage, spirit—then to that degree
you have an existentialist sensibility.
I must be careful not to slip off the surface of these pages and glide into another book.
This is not the place to discuss in any depth the existential frame of reference in therapy. I
refer interested readers to my book, Existential Psychotherapy58 and to my other books
that portray the existential clinical approach in action, Love’s Executioner,59 When
Nietzsche Wept,60 The Gift of Therapy,61 Momma and the Meaning of Life,62 and, The
Schopenhauer Cure.63 For now, it is sufficient to note that modern existential therapy
represents an application of two merged philosophical traditions. The first is substantive:
Lebensphilosophie (the philosophy of life, or philosophical anthropology); and the second
is methodological: phenomenology, a more recent tradition, fathered by Edmund Husserl,
which argues that the proper realm of the study of the human being is consciousness itself.
From a phenomenological approach, understanding takes place from within; hence, we
must bracket the natural world and attend instead to the inner experience that is the author
of that world.
The existential therapeutic approach—with its emphasis on awareness of death,
freedom, isolation, and life purpose—has been, until recently, far more acceptable to the
European therapeutic community than to the American one. The European philosophic
tradition, the geographic and ethnic confinement, and the greater familiarity with limits,
war, death, and uncertain existence all favored the spread of the existential influence. The
American zeitgeist of expansiveness, optimism, limitless horizons, and pragmatism
embraced instead the scientific positivism proffered by a mechanistic Freudian
metaphysics or a hyperrational, empirical behaviorism (strange bedfellows!).
During the past four decades, there has been a major development in American
psychotherapy: the emergence of what has come to be known as the third force in
American psychology (after Freudian psychoanalysis and Watsonian behaviorism). This
force, often labeled “existential” or “humanistic,” has had an enormous influence on
modern therapeutic practice.
Note, however, that we have done more than imported the European existential
tradition; we have Americanized it. Thus, although the syntax of humanistic psychology is
European, the accent is unmistakably New World. The European focus is on the tragic
dimensions of existence, on limits, on facing and taking into oneself the anxiety of
uncertainty and nonbeing. The American humanistic psychologists, on the other hand,
speak less of limits and contingency than of human potentiality, less of acceptance than of
awareness, less of anxiety than of peak experiences and oceanic oneness, less of life
meaning than of self-realization, less of apartness and basic isolation than of I-Thou and
encounter.
Of course, when a basic doctrine has a number of postulates and the accent of each is
systematically altered in a specific direction, there is a significant risk of aberration from
the original doctrine. To some extent this has occurred, and some humanistic
psychologists have lost touch with their existential roots and espouse a monolithic goal of
self-actualization with an associated set of quick actualizing techniques. This is a most

unfortunate development. It is important to keep in mind that the existential approach in
therapy is not a set of technical procedures but basically an attitude, a sensibility toward
the facts of life inherent in the human condition.
Existential therapy is a dynamic approach based on concerns that are rooted in
existence. Earlier I mentioned that a “dynamic” approach refers to a therapy that assumes
that the deep structures of personality encompass forces that are in conflict with one
another, and (this point is very important) these forces exist at different levels of
awareness: indeed, some exist outside of conscious awareness. But what about the content
of the internal struggle?
The existential view of the content differs greatly from the other dynamic systems. A
classical analytic approach, for example, addresses the struggle between the individual’s
fundamental drives (primarily sexual and aggressive) and an environment that frustrates
satisfaction of those drives. Alternatively, a self psychology approach would attend to the
individual’s efforts to preserve a stable sense of self as vital and worthwhile in the context
of resonating or disappointing self-object relationships.
The existential approach holds that the human being’s paramount struggle is with the
“givens” of existence, the ultimate concerns of the human condition: death, isolation,
freedom, and meaninglessness. Anxiety emerges from basic conflicts in each of these
realms: (1) we wish to continue to be and yet are aware of inevitable death; (2) we crave
structure and yet must confront the truth that we are the authors of our own life design and
our beliefs and our neural apparatus is responsible for the form of reality: underneath us
there is Nichts, groundlessness, the abyss; (3) we desire contact, protection, to be part of a
larger whole, yet experience the unbridgeable gap between self and others; and (4) we are
meaning-seeking creatures thrown into a world that has no intrinsic meaning.
The items in the Q-sort that struck meaningful chords in the study subjects reflected
some of these painful truths about existence. Group members realized that there were
limits to the guidance and support they could receive from others and that the ultimate
responsibility for the conduct of their lives was theirs alone. They learned also that though
they could be close to others, there was a point beyond which they could not be
accompanied: there is a basic aloneness to existence that must be faced. Many clients
learned to face their limitations and their mortality with greater candor and courage.
Coming to terms with their own deaths in a deeply authentic fashion permits them to cast
the troublesome concerns of everyday life in a different perspective. It permits them to
trivialize life’s trivia.
We often ignore these existential givens, until life events increase our sensibilities. We
may at first respond to illness, bereavement, and trauma with denial, but ultimately the
impact of these life-altering events may break through to create a therapeutic opportunity
that may catalyze constructive changes in oneself, one’s relationships, and one’s
relationship to life in general.†64
After ten sessions of integrative group therapy, women with early-stage breast cancer
not only experienced more optimism and reduced depression and anxiety but also
concluded that their cancer had contributed positively to their lives by causing them to

realign their life priorities. 65 In addition they showed a significant reduction in levels of
the stress hormone cortisol.66 Members of such support groups may benefit
psychologically, emotionally, and even physically as a result of the group’s support for
meaningful engagement with life challenges (see chapter 15).67
The course of therapy of Sheila, a client who at the end of treatment selected the
existential Q-sort items as having been instrumental in her improvement, illustrates many
of these points.
• A twenty-five-year-old perennial student, 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 could not discover what precisely she meant, and since this complaint was
embedded in a litany of self-accusations, I soon forgot it. However, she did not
understand what happened to her in the group, either: she could not understand
why others were so uninterested in her, why she developed a conversion paralysis,
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, 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, 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 benign). She had
never been so near to her own death before, 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 a
social loneliness, an inability to be with others.
Social loneliness is commonly and easily worked with in a group therapeutic
setting. Basic loneliness is more hidden, more obscured by the distractions of

everyday life, 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 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. Choice and freedom invariably
imply loneliness, and, as Fromm pointed out long ago in Escape from Freedom,
freedom holds more terror for us than tyranny does.68
Turn back again to table 4.1. Let us consider item 60, which so many clients rated so
highly: Learning that I must take ultimate responsibility for the way I live my life no
matter how much guidance and support I get from others. In a sense, this is a double-
edged factor in group therapy. Group members learn a great deal about how to relate
better, how to develop greater intimacy with others, how to give help and to ask for help
from others. At the same time, they discover the limits of intimacy; they learn what they
cannot obtain from others. It is a harsh lesson and leads to both despair and strength. One
cannot stare at the sun very long, and Sheila on many occasions looked away and avoided
her dread. But she was always able to return to it, and by the end of therapy had made
major shifts within herself.
An important concept in existential therapy is that human beings may relate to the
ultimate concerns of existence in one of two possible modes. On the one hand, we may
suppress or ignore our situation in life and live in what Heidegger termed a state of
forgetfulness of being.69 In this everyday mode, we live in the world of things, in everyday
diversions; we are absorbed in chatter, tranquilized, lost in the “they”; we are concerned
only about the way things are. On the other hand, we may exist in a state of mindfulness of
being, a state in which we marvel not at the way things are, but that they are. In this state,
we are aware of being; we live authentically; we embrace our possibilities and limits; we
are aware of our responsibility for our lives. (I prefer Sartre’s definition of responsibility:
“to be responsible is to be the “uncontested author of… ”.)70
Being aware of one’s self-creation in the authentic state of mindfulness of being
provides one with the power to change and the hope that one’s actions will bear fruit.†
Thus, the therapist must pay special attention to the factors that transport a person from
the everyday to the authentic mode of existing. One cannot effect such a shift merely by
bearing down, by gritting one’s teeth. But there are certain jolting experiences (often
referred to in the philosophical literature as “boundary experiences”) that effectively
transport one into the mindfulness-of-being state.71
An extreme experience—such as Sheila’s encounter with a possibly malignant tumor—
is a good example of a boundary experience, an event that brings one sharply back to

reality and helps one prioritize one’s concerns in their proper perspective. Extreme
experience, however, occurs in its natural state only rarely during the course of a therapy
group, and the adept leader finds other ways to introduce these factors. The growing
emphasis on brief therapy offers an excellent opportunity: the looming end of the group
(or, for that matter, individual therapy) may be used by the therapist to urge clients to
consider other terminations, including death, and to reconsider how to improve the quality
and satisfaction of their remaining time. It is in this domain that the existential and
interpersonal intersect as clients begin to ask themselves more fundamental questions:
What choices do I exercise in my relationships and in my behavior? How do I wish to be
experienced by others? Am I truly present and engaged in this relationship or am I
managing the relationship inauthentically to reduce my anxiety? Do I care about what this
person needs from me or am I motivated by my constricted self-interest?
Other group leaders attempt to generate extreme experience by using a form of
existential shock therapy. With a variety of techniques, they try to bring clients to the edge
of the abyss of existence. I have seen leaders begin personal growth groups, for example,
by asking clients to compose their own epitaphs. Other leaders may begin by asking
members to draw their lifeline and mark their present position on it: How far from birth?
How close to death? But our capacity for denial is enormous, and it is the rare group that
perseveres, that does not slip back into less threatening concerns. Natural events in the
course of a group—illness, death, termination, and loss—may jolt the group back, but
always temporarily.
In 1974, I began to lead groups of individuals who lived continuously in the midst of
extreme experience.72 All the members had a terminal illness, generally metastatic
carcinoma, and all were entirely aware of the nature and implications of their illness. I
learned a great deal from these groups, especially about the fundamental but concealed
issues of life that are so frequently neglected in traditional psychotherapy. (See Chapter 15
for a detailed description of this group and current applications of the supportive-
expressive group approach.)
Reflecting back on that initial therapy group for cancer patients, many features stand
out. For one thing, the members were deeply supportive to one another, and it was
extraordinarily helpful for them to be so. Offering help so as to receive it in reciprocal
fashion was only one, and not the most important, benefit of this supportiveness. Being
useful to someone else drew them out of morbid self-absorption and provided them with a
sense of purpose and meaning. Almost every terminally ill person I have spoken to has
expressed deep fear of a helpless immobility—not only of being a burden to others and
being unable to care for themselves but of being useless and without value to others.
Living, then, becomes reduced to pointless survival, and the individual searches within,
ever more deeply, for meaning. The group offered these women the opportunity to find
meaning outside themselves: by extending help to another person, by caring for others,
they found the sense of purpose that so often eludes sheer introspective reflection.k
These approaches, these avenues to self-transcendence, if well traveled, can increase
one’s sense of meaning and purpose as well as one’s ability to bear what cannot be

changed. Finding meaning in the face of adversity can be transformative.73 Long ago,
Nietzsche wrote: “He who has a why to live can bear with almost any how.”74
It was clear to me (and demonstrated by empirical research) that the members of this
group who plunged most deeply into themselves, who confronted their fate most openly
and resolutely, passed into a richer mode of existence.75 Their life perspective was
radically altered; the trivial, inconsequential diversions of life were seen for what they
were. Their neurotic phobias diminished. They appreciated more fully the elemental
features of living: the changing seasons, the previous spring, the falling leaves, the loving
of others. Rather than resignation, powerlessness, and restriction, some members have
experienced a great sense of liberation and autonomy.
Some even spoke of the gift of cancer. What some considered tragic, was not their death
per se, but that they learned how to live life fully only after being threatened by serious
illness. They wondered if it was possible to teach their loved ones this important lesson
earlier in life or if it could be learned only in extremis? It may be that through the act of
death ending life, the idea of death revitalizes life: death becomes a co-therapist pushing
the work of psychotherapy ahead.
What can you as therapist do in the face of the inevitable? I think the answer lies in the
verb to be. You do by being, by being there with the client. Presence is the hidden agent of
help in all forms of therapy. Clients looking back on their therapy rarely remember a
single interpretation you made, but they always remember your presence, that you were
there with them. It is asking a great deal of the therapist to join this group, yet it would be
hypocrisy not to join. The group does not consist of you (the therapist), and they (the
dying); it is we who are dying, we who are banding together in the face of our common
condition. In my book The Gift of Therapy, I propose that the most accurate or felicitous
term for the therapeutic relationship might be “fellow traveler.” Two hundred years ago,
Schopenhauer suggested we should address one another as “fellow sufferers.”76
The group well demonstrates the double meaning of the word apartness: we are
separate, lonely, apart from but also a part of. One of my members put it elegantly when
she described herself as a lonely ship in the dark. Even though no physical mooring could
be made, it was nonetheless enormously comforting to see the lights of other ships sailing
the same water.
COMPARATIVE VALUE OF THE THERAPEUTIC
FACTORS: DIFFERENCES BETWEEN CLIENTS’ AND
THERAPISTS’ VIEWS
Do clients and therapists agree about what helps in group psychotherapy? Research
comparing therapists’ and clients’ assessments is instructive. First, keep in mind that
therapists’ published views of the range of therapeutic factors are broadly analogous to the

factors I have described.77 But, of course, leaders from different ideological schools differ
in their weighting of the therapeutic factors, even though they resemble one another in
their therapeutic relationships.78
The research data tells us that therapists and clients differ in their valuation of the group
therapeutic factors. A study of 100 acute inpatient group members and their thirty
behaviorally oriented therapists showed that the therapists and clients differed
significantly in their ranking of therapeutic factors. Therapists placed considerably more
weight on client modeling and behavioral experimentation, whereas the group members
valued other factors more: self-responsibility, self-understanding, and universality.79
Another study showed that groups of alcoholics ranked existential factors far higher than
did their therapists.80 It should not be surprising that substance abuse clients value
accountability and personal responsibility highly. These factors are cornerstones of
twelve-step groups.
Fifteen HIV-positive men treated in time-limited cognitive-behavioral therapy groups
for depression cited different therapeutic factors than their therapists. Members selected
social support, cohesion, universality, altruism, and existential factors, whereas the
therapists (in line with their ideological school) considered cognitive restructuring as the
mutative agent.81
A large survey of prison therapy groups notes that inmates agree with their group
leaders about the importance of interpersonal learning but value existential factors far
more highly than their therapists do.82 As noted earlier, incest victims in group therapy
value highly the therapeutic factor of family reenactment.83
Therapists are wise to be alert to these divergences. Client-therapist disagreement about
the goals and tasks of therapy may impair the therapeutic alliance.† This issue is not
restricted to group therapy. Client-therapist discrepancies on therapeutic factors also occur
in individual psychotherapy. A large study of psychoanalytically oriented therapy found
that clients attributed their successful therapy to relationship factors, whereas their
therapists gave precedence to technical skills and techniques.84 In general, analytic
therapists value the coming to consciousness of unconscious factors and the subsequent
linkage between childhood experiences and present symptoms far more than do their
clients, who deny the importance or even the existence of these elements in therapy;
instead they emphasize the personal elements of the relationship and the encounter with a
new, accepting type of authority figure.
A turning point in the treatment of one client starkly illustrates the differences. In the
midst of treatment, the client had an acute anxiety attack and was seen by the therapist in
an emergency session. Both therapist and client regarded the incident as critical, but for
very different reasons. To the therapist, the emergency session unlocked the client’s
previously repressed memories of early incestuous sex play and facilitated a working-
through of important Oedipal material. The client, on the other hand, entirely dismissed
the content of the emergency session and instead valued the relationship implications: the
caring and concern expressed by the therapist’s willingness to see him in the middle of the

night.
A similar discrepancy between the client’s and the therapist’s view of therapy is to be
found in Every Day Gets a Little Closer, a book I coauthored with a client.85 Throughout
the treatment she and I wrote independent, impressionistic summaries of each meeting and
handed them in, sealed, to my secretary. Every few months we read each other’s
summaries and discovered that we valued very different aspects of the therapeutic process.
All my elegant interpretations? She never even heard them! What she remembered and
treasured were the soft, subtle, personal exchanges, which, to her, conveyed my interest
and caring for her.
Reviews of process and outcome research reveal that clients’ ratings of therapist
engagement and empathy are more predictive of therapeutic success than therapists’
ratings of these same variables.86 These findings compel us to pay close attention to the
client’s view of the most salient therapeutic factors. In research as in clinical work, we do
well to heed the adage: Listen to the client.
To summarize: Therapists and their clients differ in their views about important
therapeutic factors: clients consistently emphasize the importance of the relationship and
the personal, human qualities of the therapist, whereas therapists attribute their success to
their techniques. When the therapist-client discrepancy is too great, when therapists
emphasize therapeutic factors that are incompatible with the needs and capacities of the
group members, then the therapeutic enterprise will be derailed: clients will become
bewildered and resistant, and therapists will become discouraged and exasperated. The
therapist’s capacity to respond to client vulnerability with warmth and tenderness is
pivotal and may lie at the heart of the transformative power of therapy.†
THERAPEUTIC FACTORS: MODIFYING FORCES
It is not possible to construct an absolute hierarchy of therapeutic factors. There are many
modifying forces: therapeutic factors are influenced by the type of group therapy, the stage
of therapy, extragroup forces, and individual differences.
Therapeutic Factors in Different Group Therapies
Different types of group therapy favor the operation of different clusters of curative
factors. Consider, for example, the therapy group on an acute inpatient ward. Members of
inpatient therapy groups do not select the same constellation of three factors (interpersonal
learning, catharsis, and self-understanding) as most members of outpatient groups.87
Rather, they select a wide range of therapeutic factors that reflect, I believe, both the
heterogeneous composition of inpatient therapy groups and the cafeteria theory of
improvement in group therapy. Clients who differ greatly from one another in ego
strength, motivation, goals, and type and severity of psychopathology meet in the same
inpatient group and, accordingly, select and value different aspects of the group procedure.

Many more inpatients than outpatients select the therapeutic factors of instillation of
hope and existential factors (especially the assumption of responsibility). Instillation of
hope looms large in inpatient groups because so many individuals enter the hospital in a
state of utter demoralization. Until the individual acquires hope and the motivation to
engage in treatment, no progress will be made. Often the most effective antidote to
demoralization is the presence of others who have recently been in similar straits and
discovered a way out of despair. Existential factors (defined on the research instruments
generally as “assumption of ultimate responsibility for my own life”) are of particular
importance to inpatients, because often hospitalization confronts them with the limits of
other people; external resources have been exhausted; family, friends, therapists have
failed; they have hit bottom and realize that, in the final analysis, they can rely only on
themselves. (On one inpatient Q-sort study, the assumption of responsibility, item 60, was
ranked first of the sixty items.)88
A vast range of homogeneously composed groups meet today. Let us review the
therapeutic factors chosen by the members of several of these groups.
• Alcoholics Anonymous and Recovery, Inc. members emphasize the instillation of
hope, imparting information, universality, altruism, and some aspects of group
cohesiveness.
• Members of discharge planning groups in psychiatric hospitals emphasize imparting
of information and development of socializing techniques.
• Participants of occupational therapy groups most valued the factors of cohesiveness,
instillation of hope, and interpersonal learning.89
• Members of psychodrama groups in Israel, despite differences in culture and
treatment format, selected factors consistent with those selected by group therapy
outpatients: interpersonal learning, catharsis, group cohesiveness, and self-
understanding.90
• Members of self-help groups (women’s consciousness raising, bereaved parents,
widows, heart surgery patients, and mothers) commonly chose factors of
universality, followed by guidance, altruism, and cohesiveness.91
• Members of an eighteen-month-long group of spouses caring for a partner with a
brain tumor chose universality, altruism, instillation of hope, and the provision of
information.92
• Psychotic clients with intrusive, controlling auditory hallucinations successfully
treated in cognitive-behavioral therapy groups valued universality, hope, and
catharsis. For them, finally being able to talk about their voices and feel
understood by peers was of enormous value.93
• Spousal abusers in a psychoeducational group selected the imparting of information
as a chief therapeutic factor.94
• Adolescents in learning disability groups cited the effectiveness of “mutual

recognition”—of seeing oneself in others and feeling valued and less isolated.95
• Geriatric group participants who confront limits, mortality, and the passage of time
select existential factors as critically important.96
When therapists form a new therapy group in some specialized setting or for some
specialized clinical population, the first step, as I will stress in chapter 15, is to determine
the appropriate goals and, after that, the therapeutic factors most likely to be helpful for
that particular group. Everything else, all matters of therapeutic technique, follow from
that framework. Thus, it is vitally important to keep in mind the persuasive research
evidence that different types of group therapy make use of different therapeutic factors.
For example, consider a time-limited psychoeducational group for panic attacks whose
members may receive considerable benefit from group leader instruction on cognitive
strategies for preventing and minimizing the disruptiveness of the attacks (guidance). The
experience of being in a group of people who suffer from the same problem (universality)
is also likely to be very comforting. Although difficulties in relationships may indeed
contribute to their symptoms, an undue focus on the therapeutic factor of interpersonal
learning would not be warranted given the time frame of the group.
Understanding the client’s experience of the therapeutic factors can lead to enlightened
and productive group innovations. For example, an effective multimodal group approach
for bulimia nervosa has been reported that integrates and sequences three independently
effective treatments. This twelve-week group starts with a psychoeducation module about
bulimia and nutrition; next is a cognitive-behavioral module that examines distorted
cognitions about eating and body image; and the group concludes with an interpersonally
oriented group segment that examines here-and-now relationship concerns and their
impact on eating behaviors.97
Therapeutic Factors and Stages of Therapy
Intensive interactional group therapy exerts its chief therapeutic power through
interpersonal learning (encompassing catharsis, self-understanding, and interpersonal
input and output) and group cohesiveness, but the other therapeutic factors play an
indispensable role in the intensive therapy process. To appreciate the interdependence of
the therapeutic factors, we must consider the entire group process from start to finish.
Many clients expressed difficulty in rank-ordering therapeutic factors because they
found different factors helpful at different stages of therapy. Factors of considerable
importance early in therapy may be far less salient late in the course of treatment.
Consider the early stages of development: the group’s chief concerns are with survival,
establishing boundaries, and maintaining membership. In this phase, factors such as the
instillation of hope, guidance, and universality are especially important.†98 A universality
phase early in the group is inevitable as well, as members search out similarities and
compare symptoms and problem constellations.

The first dozen meetings of a group present a high-risk period for potential dropouts,
and it is often necessary to awaken hope in the members in order to keep them attending
through this critical phase. Factors such as altruism and group cohesiveness operate
throughout therapy, but their nature changes with the stage of the group. Early in therapy,
altruism takes the form of offering suggestions or helping one another talk by asking
appropriate questions and giving attention. Later it may take the form of a more profound
caring and presence.
Group cohesiveness operates as a therapeutic factor at first by means of group support,
acceptance, and the facilitation of attendance and later by means of the interrelation of
group esteem and self-esteem and through its role in interpersonal learning. It is only after
the development of group cohesiveness that members may engage deeply and
constructively in the self-disclosure, confrontation, and conflict essential to the process of
interpersonal learning. Therapists must appreciate this necessary developmental sequence
to help prevent early group dropouts. In a study of therapeutic factors in long-term
inpatient treatment in Germany, clinical improvement was related to the experience of
early cohesion and belonging. Cohesion set the stage for greater personal self-disclosure,
which generated the interpersonal feedback that produced behavioral and psychological
change.99 An outpatient study demonstrated that the longer group members participated in
the group, the more they valued cohesiveness, self-understanding, and interpersonal
output.100 Students in eleven-session counseling groups valued universality more in the
first half of the group and interpersonal learning in the second half.101
In a study of twenty-six-session growth groups, universality and hope declined in
importance through the course of the group, whereas catharsis increased.102 In a study of
spouse abusers, universality was the prominent factor in early stages, while the importance
of group cohesion grew over time.103 This emphasis on universality may be characteristic
in the treatment of clients who feel shame or stigma. The cohesion that promotes change,
however, is best built on a respect and acceptance of personal differences that takes time
to mature. In another study, psychiatric inpatients valued universality, hope, and
acceptance most, but later, when they participated in outpatient group psychotherapy, they
valued self-understanding more.104
In summary, the therapeutic factors clients deem most important vary with the stage of
group development. The therapist’s attention to this finding is as important as the
therapist’s congruence with the client on therapeutic factors reviewed in the preceding
section. Clients’ needs and goals change during the course of therapy. In chapter 2, I
described a common sequence in which group members first seek symptomatic relief and
then, during the first months in therapy, formulate new goals, often interpersonal ones of
relating more deeply to others, learning to love, and being honest with others. As
members’ needs and goals shift during therapy, so, too, must the necessary therapeutic
processes. Modern enlightened psychotherapy is often termed dynamic psychotherapy
because it appreciates the dynamics, the motivational aspects of behavior, many of which
are not in awareness. Dynamic therapy may be thought of also as changing, evolving
psychotherapy: clients change, the group goes through a developmental sequence, and the

therapeutic factors shift in primacy and influence during the course of therapy.
Therapeutic Factors Outside the Group
Although I suggest that major behavioral and attitudinal shifts require a degree of
interpersonal learning, occasionally group members make major changes without making
what would appear to be the appropriate investment in the therapeutic process. This brings
up an important principle in therapy: The therapist or the group does not have to do the
entire job. Personality reconstruction as a therapeutic goal is as unrealistic as it is
presumptuous. Our clients have many adaptive coping strengths that may have served
them well in the past, and a boost from some event in therapy may be sufficient to help a
client begin coping in an adaptive manner. Earlier in this text I used the term “adaptive
spiral” to refer to the process in which one change in a client begets changes in his or her
interpersonal environment that beget further personal change. The adaptive spiral is the
reverse of the vicious circle, in which so many clients find themselves ensnared—a
sequence of events in which dysphoria has interpersonal manifestations that weaken or
disrupt interpersonal bonds and consequently create further dysphoria.
These points are documented when we ask clients about other therapeutic influences or
events in their lives that occurred concurrently with their therapy course. In one sample of
twenty clients, eighteen described a variety of extragroup therapeutic factors. Most
commonly cited was a new or an improved interpersonal relationship with one or more of
a variety of figures (member of the opposite sex, parent, spouse, teacher, foster family, or
new set of friends).105 Two clients claimed to have benefited by going through with a
divorce that had long been pending. Many others cited success at work or school, which
raised their self-esteem as they established a reservoir of real accomplishments. Others
became involved in some new social venture (a YMCA group or community action
group).
Perhaps these are fortuitous, independent factors that deserve credit, along with group
therapy, for the successful outcome. In one sense that is true: the external event augments
therapy. Yet it is also true that the potential external event had often always been there: the
therapy group mobilized the members to take advantage of resources that had long been
available to them in their environment.
Consider Bob, a lonely, shy, and insecure man, who attended a time-limited twenty-
five-session group. Though he spent considerable time discussing his fear about
approaching women, and though the group devoted much effort to helping him, there
seemed little change in his outside behavior. But at the final meeting of the group, Bob
arrived with a big smile and a going-away present for the group: a copy of a local
newspaper in which he had placed an ad in the personals!
The newspapers, spouses, online sites, relatives, potential friends, social organizations,
and academic or job opportunities are always out there, available, waiting for the client to
seize them. The group may have given the client only the necessary slight boost to allow

him or her to exploit these previously untapped resources. Frequently the group members
and the therapist are unaware of the importance of these factors and view the client’s
improvement with skepticism or puzzlement. And frequently the group may end with no
evidence of their ultimate impact on the member. Later, when I discuss combined
treatment, I will emphasize the point that therapists who continue to see clients in
individual therapy long after the termination of the group often learn that members make
use of the internalized group months, even years, later.
A study of encounter group members who had very successful outcomes yielded
corroborative results.106 More often than not, successful members did not credit the group
for their change. Instead, they described the beneficial effects of new relationships they
had made, new social circles they had created, new recreational clubs they had joined,
greater work satisfaction they had found. Closer inquiry indicated, of course, that the
relationships, social circles, recreational clubs, and work satisfaction had not suddenly and
miraculously materialized. They had long been available to the individual who was
mobilized by the group experience to take advantage of these resources and exploit them
for satisfaction and personal growth.
I have considered, at several places in this text, how the skills group members acquire
prepare them for new social situations in the future. Not only are extrinsic skills acquired
but intrinsic capacities are released. Psychotherapy removes neurotic obstructions that
have stunted the development of the client’s own resources. The view of therapy as
obstruction removal lightens the burden of therapists and enables them to retain respect
for the rich, never fully knowable, capacities of their clients.
Individual Differences and Therapeutic Factors
The studies cited in this chapter report average values of therapeutic factors as ranked by
groups of clients. However, there is considerable individual variation in the rankings, and
some researchers have attempted to determine the individual characteristics that influence
the selection of therapeutic factors. Although demographic variables such as sex and
education make little difference, there is evidence that level of functioning is significantly
related to the ranking of therapeutic factors, for example, higher-functioning individuals
value interpersonal learning (the cluster of interpersonal input and output, catharsis, and
self-understanding) more than do the lower-functioning members in the same group.107 It
has also been shown that lower-functioning inpatient group members value the instillation
of hope, whereas higher-functioning members in the same groups value universality,
vicarious learning, and interpersonal learning.108
A large number of other studies demonstrate differences between individuals (high
encounter group learners vs. low learners, dominant vs. nondominant clients, overly
responsible vs. nonresponsible clients, high self acceptors vs. low self acceptors, highly
affiliative vs. low affiliative students).109
Not everyone needs the same things or responds in the same way to group therapy.

There are many therapeutic pathways through the group therapy experience. Consider, for
example, catharsis. Some restricted individuals benefit by experiencing and expressing
strong affect, whereas others who have problems of impulse control and great emotional
liability may not benefit from catharsis but instead from reining in emotional expression
and acquiring intellectual structure. Narcissistic individuals need to learn to share and to
give, whereas passive, self-effacing individuals need to learn to express their needs and to
become more selfish. Some clients may need to develop satisfactory, even rudimentary,
social skills; others may need to work with more subtle issues—for example, a male client
who needs to stop sexualizing all women and devaluing or competing with all men.
In summary, it is clear that the comparative potency of the therapeutic factors is a
complex issue. Different factors are valued by different types of therapy groups, by the
same group at different developmental stages, and by different clients within the same
group, depending on individual needs and strengths. Overall, however, the preponderance
of research evidence indicates that the power of the interactional outpatient group
emanates from its interpersonal properties. Interpersonal interaction and exploration
(encompassing catharsis and self-understanding) and group cohesiveness are the sine qua
non of effective group therapy, and effective group therapists must direct their efforts
toward maximal development of these therapeutic resources. The next chapters will
consider the role and the techniques of the group therapist from the viewpoint of these
therapeutic factors.

Chapter 5
THE THERAPIST: BASIC TASKS
Now that I have considered how people change in group therapy, it is time to turn to the
therapist’s role in the therapeutic process. In this chapter, I consider the basic tasks of the
therapist and the techniques by which they may be accomplished.
The four previous chapters contend that therapy is a complex process consisting of
elemental factors that interlace in an intricate fashion. The group therapist’s job is to create
the machinery of therapy, to set it in motion, and to keep it operating with maximum
effectiveness. Sometimes I think of the therapy group as an enormous dynamo: often the
therapist is deep in the interior—working, experiencing, interacting (and being personally
influenced by the energy field); at other times, the therapist dons mechanic’s clothes and
tinkers with the exterior, lubricating, tightening nuts and bolts, replacing parts.
Before turning to specific tasks and techniques, I wish to emphasize something to which
I will return again and again in the following pages. Underlying all considerations of
technique must be a consistent, positive relationship between therapist and client. The
basic posture of the therapist to a client must be one of concern, acceptance, genuineness,
empathy . Nothing, no technical consideration, takes precedence over this attitude. Of
course, there will be times when the therapist challenges the client, shows frustration, even
suggests that if the client is not going to work, he or she should consider leaving the
group. But these efforts (which in the right circumstances may have therapeutic clout) are
never effective unless they are experienced against a horizon of an accepting, concerned
therapist-client relationship.
I will discuss the techniques of the therapist in respect to three fundamental tasks:
1. Creation and maintenance of the group
2. Building a group culture
3. Activation and illumination of the here-and-now
I discuss the first of these only briefly here and will pick it up in greater detail after I
present the essential background material of chapters 8, 9, and 10. In this chapter, I focus
primarily on the second task, building a group culture, and, in the next chapter turn to the
third task, the activation and illumination of the here-and-now.
CREATION AND MAINTENANCE OF THE GROUP
The group leader is solely responsible for creating and convening the group. Your offer of
professional help serves as the group’s initial raison d’être, and you set the time and place
for meetings. A considerable part of the maintenance task is performed before the first

meeting, and, as I will elaborate in later chapters, the leader’s expertise in the selection
and the preparation of members will greatly influence the group’s fate.
Once the group begins, the therapist attends to gatekeeping, especially the prevention of
member attrition. Occasionally an individual will have an unsuccessful group experience
resulting in premature termination of therapy, which may play some useful function in his
or her overall therapy career. For example, failure in or rejection by a group may so
unsettle the client as to prime him or her ideally for another therapist. Generally, however,
a client who drops out early in the course of the group should be considered a therapeutic
failure. Not only does the client fail to receive benefit, but the progress of the remainder of
the group is adversely affected. Stability of membership is a sine qua non of successful
therapy. If dropouts do occur, the therapist must, except in the case of a closed group (see
chapter 10), add new members to maintain the group at its ideal size.
Initially, the clients are strangers to one another and know only the therapist, who is the
group’s primary unifying force. The members relate to one another at first through their
common relationship with the therapist, and these therapist-client alliances set the stage
for the eventual development of group cohesion.
The therapist must recognize and deter any forces that threaten group cohesiveness.
Continued tardiness, absences, subgrouping, disruptive extragroup socialization, and
scapegoating all threaten the functional integrity of the group and require the intervention
of the therapist. Each of these issues will be discussed fully in later chapters. For now, it is
necessary only to emphasize the therapist’s responsibility to supra-individual needs. Your
first task is to help create a physical entity, a cohesive group. There will be times when
you must delay dealing with pressing needs of an individual client, and even times when
you will have to remove a member from the group for the good of the other members.
A clinical vignette illustrates some of these points:
• Once I introduced two new members, both women, into an outpatient group. This
particular group, with a stable core of four male members, had difficulty keeping
women members and two women had dropped out in the previous month. This
meeting began inauspiciously for one of the women, whose perfume triggered a
sneezing fit in one of the men, who moved his chair away from her and then, while
vigorously opening the windows, informed her of his perfume allergy and of the
group’s “no perfume” rule.
At this point another member, Mitch, arrived a couple of minutes late and,
without even a glance at the two new members, announced, “I need some time
today from the group. I was really shook up by the meeting last week. I went home
from the group very disturbed by your comments about my being a time hog. I
didn’t like those insinuations from any of you, or from you either [addressing me].
Later that evening I had an enormous fight with my wife, who took exception to my
reading a medical journal [Mitch was a physician] at the dinner table, and we
haven’t been speaking since.”
Now this particular opening is a good beginning for most group meetings. It had

many things going for it. The client stated that he wanted some time. (The more
members who come to the group asking for time and eager to work, the more
energized a meeting will be.) Also, he wanted to work on issues that had been
raised in the previous week’s meeting. (As a general rule the more group members
work on themes continually from meeting to meeting, the more powerful the group
becomes.) Furthermore, he began the meeting by attacking the therapist—and that
was a good thing. This group had been treating me much too gently. Mitch’s attack,
though uncomfortable, was, I felt certain, going to produce important group work.
Thus I had many different options in the meeting, but there was one task to
which I had to award highest priority: maintaining the functional integrity of the
group. I had introduced two female members into a group that had had some
difficulty retaining women. And how had the members of the group responded? Not
well! They had virtually disenfranchised the new members. After the sneezing
incident, Mitch had not even acknowledged their presence and had launched into
an opening gambit—that, though personally important, systematically excluded the
new women by its reference to the previous meeting.
It was important, then, for me to find a way to address this task and, if possible,
also to address the issues Mitch had raised. In chapter 2, I offered the basic
principle that therapy should strive to turn all issues into here-and-now issues. It
would have been folly to deal explicitly with Mitch’s fight with his wife. The data
that Mitch would have given about his wife would have been biased and he might
well have “yes, but” the group to death.
Fortunately, however, there was a way to tackle both issues at once. Mitch’s
treatment of the two women in the group bore many similarities to his treatment of
his wife at the dinner table. He had been as insensitive to their presence and their
particular needs as to his wife’s. In fact, it was precisely about his insensitivity that
the group had confronted him the previous meeting.
Therefore, about a half hour into the meeting, I pried Mitch’s attention away
from his wife and last week’s session by saying, “Mitch, I wonder what hunches
you have about how our two new members are feeling in the group today?”
This inquiry led Mitch into the general issue of empathy and his inability or
unwillingness in many situations to enter the experiential world of the other.
Fortunately, this tactic not only turned the other group members’ attention to the
way they all had ignored the two new women, but also helped Mitch work
effectively on his core problem: his failure to recognize and appreciate the needs
and wishes of others. Even if it were not possible to address some of Mitch’s
central issues, I still would have opted to attend to the integration of the new
members. Physical survival of the group must take precedence over other tasks.
CULTURE BUILDING

Once the group is a physical reality, the therapist’s energy must be directed toward
shaping it into a therapeutic social system. An unwritten code of behavioral rules or norms
must be established that will guide the interaction of the group. And what are the desirable
norms for a therapeutic group? They follow logically from the discussion of the
therapeutic factors.
Consider for a moment the therapeutic factors outlined in the first four chapters:
acceptance and support, universality, advice, interpersonal learning, altruism, and hope—
who provides these? Obviously, the other members of the group! Thus, to a large extent, it
is the group that is the agent of change.
Herein lies a crucial difference in the basic roles of the individual therapist and the
group therapist. In the individual format, the therapist functions as the solely designated
direct agent of change. The group therapist functions far more indirectly. In other words, if
it is the group members who, in their interaction, set into motion the many therapeutic
factors, then it is the group therapist’s task to create a group culture maximally conducive
to effective group interaction.
The game of chess provides a useful analogy. Expert players do not, at the beginning of
the game, strive for checkmate or outright capture of a piece, but instead aim at obtaining
strategic squares on the board, thereby increasing the power of each of their pieces. In so
doing, players are indirectly moving toward success since, as the game proceeds, this
superior strategic position will favor an effective attack and ultimate material gain. So,
too, the group therapist methodically builds a culture that will ultimately exert great
therapeutic strength.
A jazz pianist, a member of one of my groups, once commented on the role of the leader
by reflecting that very early in his musical career, he deeply admired the great
instrumental virtuosos. It was only much later that he grew to understand that the truly
great jazz musicians were those who knew how to augment the sound of others, how to be
quiet, how to enhance the functioning of the entire ensemble.
It is obvious that the therapy group has norms that radically depart from the rules, or
etiquette, of typical social intercourse. Unlike almost any other kind of group, the
members must feel free to comment on the immediate feelings they experience toward the
group, the other members, and the therapist. Honesty and spontaneity of expression must
be encouraged in the group. If the group is to develop into a true social microcosm,
members must interact freely. In schematic form, the pathways of interaction should
appear like the first rather than the second diagram, in which communications are
primarily to or through the therapist.

Other desirable norms include active involvement in the group, nonjudgmental
acceptance of others, extensive self-disclosure, desire for self-understanding, and an
eagerness to change current modes of behavior. Norms may be a prescription for as well
as a proscription against certain types of behavior. Norms may be implicit as well as
explicit. In fact, the members of a group cannot generally consciously elaborate the norms
of the group. Thus, to learn the norms of a group, the researcher is ill advised to ask the
members for a list of these unwritten rules. A far better approach is to present the members
with a list of behaviors and ask them to indicate which are appropriate and which
inappropriate in the group.
Norms invariably evolve in every type of group—social, professional, and therapeutic.1
By no means is it inevitable that a therapeutic group will evolve norms that facilitate the
therapeutic process. Systematic observation of therapy groups reveals that many are
encumbered with crippling norms. A group may, for example, so value hostile catharsis
that positive sentiments are eschewed; a group may develop a “take turns” format in
which the members sequentially describe their problems to the group; or a group may
have norms that do not permit members to question or challenge the therapist. Shortly I
will discuss some specific norms that hamper or facilitate therapy, but first I will consider
how norms come into being.
The Construction of Norms
Norms of a group are constructed both from expectations of the members for their group
and from the explicit and implicit directions of the leader and more influential members. If
the members’ expectations are not firm, then the leader has even more opportunity to
design a group culture that, in his or her view, will be optimally therapeutic. The group
leader’s statements to the group play a powerful, though usually implicit, role in
determining the norms established in the group.† In one study, researchers observed that

when the leader made a comment following closely after a particular member’s actions,
that member became a center of attention in the group and often assumed a major role in
future meetings. Furthermore, the relative infrequency of the leader’s comments
augmented the strength of his or her interventions.2 Researchers studying intensive
experiential training groups for group therapists also concluded that leaders who modeled
warmth and technical expertise more often had positive outcomes: members of their
groups achieved greater self-confidence and greater awareness of both group dynamics
and the role of the leader.3 In general, leaders who set norms of increased engagement and
decreased conflict have better clinical outcomes.4
By discussing the leader as norm-shaper, I am not proposing a new or contrived role for
the therapist. Wittingly or unwittingly, the leader always shapes the norms of the group
and must be aware of this function. Just as one cannot not communicate, the leader cannot
not influence norms; virtually all of his or her early group behavior is influential.
Moreover, what one does not do is often as important as what one does do.
Once I observed a group led by a British group analyst in which a member who had
been absent the six previous meetings entered the meeting a few minutes late. The
therapist in no way acknowledged the arrival of the member; after the session, he
explained to the student observers that he chose not to influence the group since he
preferred that they make their own rules about welcoming tardy or prodigal members. It
appeared clear to me, however, that the therapist’s non-welcome was an influential act and
very much of a norm-setting message. His group had evolved, no doubt as a result of
many similar previous actions, into a uncaring, insecure one, whose members sought
methods of currying the leader’s favor.
Norms are created relatively early in the life of a group and, once established, are
difficult to change. Consider, for example, the small group in an industrial setting that
forms norms regulating individual member output, or a delinquent gang that establishes
codes of behavior, or a psychiatric ward that forms norms of expected staff and patient
role behavior. To change entrenched standards is notoriously difficult and requires
considerable time and often large group membership turnover.
To summarize: every group evolves a set of unwritten rules or norms that determine the
procedure of the group. The ideal therapy group has norms that permit the therapeutic
factors to operate with maximum effectiveness. Norms are shaped both by the expectations
of the group members and by the behavior of the therapist. The therapist is enormously
influential in norm setting—in fact, it is a function that the leader cannot avoid. Norms
constructed early in the group have considerable perseverance. The therapist is thus well
advised to go about this important function in an informed, deliberate manner.
HOW DOES THE LEADER SHAPE NORMS?
There are two basic roles the therapist may assume in a group: technical expert and model-

setting participant. In each of these roles, the therapist helps to shape the norms of the
group.
The Technical Expert
When assuming the role of technical expert, therapists deliberately slip into the traditional
garb of expert and employ a variety of techniques to move the group in a direction they
consider desirable. They explicitly attempt to shape norms during their early preparation
of clients for group therapy. In this procedure, described fully in chapter 10, therapists
carefully instruct clients about the rules of the group, and they reinforce the instruction in
two ways: first, by backing it with the weight of authority and experience and, second, by
presenting the rationale behind the suggested mode of procedure in order to enlist the
clients’ support.
At the beginning of a group, therapists have at their disposal a wide choice of
techniques to shape the group culture. These range from explicit instructions and
suggestions to subtle reinforcing techniques. For example, as I described earlier, the leader
must attempt to create an interactional network in which the members freely interact rather
than direct all their comments to or through the therapist. To this end, therapists may
implicitly instruct members in their pregroup interviews or in the first group sessions; they
may, repeatedly during the meetings, ask for all members’ reactions to another member or
toward a group issue; they may ask why conversation is invariably directed toward the
therapist; they may refuse to answer questions when addressed; they may ask the group to
engage in exercises that teach clients to interact—for example, asking each member of the
group in turn to give his or her first impressions of every other member; or therapists may,
in a much less obtrusive manner, shape behavior by rewarding members who address one
another—therapists may nod or smile at them, address them warmly, or shift their posture
into a more receptive position. Exactly the same approaches may be applied to the myriad
of other norms the therapist wishes to inculcate: self-disclosure, open expression of
emotions, promptness, self-exploration, and so on.
Therapists vary considerably in style. Although many prefer to shape norms explicitly,
all therapists, to a degree often greater than they suppose, perform their tasks through the
subtle technique of social reinforcement. Human behavior is continuously influenced by a
series of environmental events (reinforcers), which may have a positive or negative
valence and which exert their influence on a conscious or a subliminal level.
Advertising and political propaganda techniques are but two examples of a systematic
harnessing of reinforcing agents. Psychotherapy, no less, relies on the use of subtle, often
nondeliberate social reinforcers. Although few self-respecting therapists like to consider
themselves social reinforcing agents, nevertheless therapists continuously exert influence
in this manner, unconsciously or deliberately. They may positively reinforce behavior by
numerous verbal and nonverbal acts, including nodding, smiling, leaning forward, or
offering an interested “mmm” or a direct inquiry for more information. On the other hand,
therapists attempt to extinguish behavior not deemed salubrious by not commenting, not

nodding, ignoring the behavior, turning their attention to another client, looking skeptical,
raising their eyebrows, and so on. In fact research suggests that therapists who reinforce
members’ pro-group behavior indirectly are often more effective than those who prompt
such behavior explicitly.5 Any obvious verbal directive from therapists then becomes
especially effective because of the paucity of such interventions.
Every form of psychotherapy is a learning process, relying in part on operant
conditioning. Therapy, even psychoanalysis, without some form of therapist reinforcement
or manipulation is a mirage that disappears on close scrutiny.6
Considerable research demonstrates the efficacy of operant techniques in the shaping of
group behavior.7 Using these techniques deliberately, one can reduce silences8 or increase
personal and group comments, expressions of hostility to the leader, or intermember
acceptance.9 Though there is evidence that they owe much of their effectiveness to these
learning principles, psychotherapists often eschew this evidence because of their
unfounded fear that such a mechanistic view will undermine the essential human
component of the therapy experience. The facts are compelling, however, and an
understanding of their own behavior does not strip therapists of their spontaneity. After all,
the objective of using operant techniques is to foster authentic and meaningful
engagement. Therapists who recognize that they exert great influence through social
reinforcement and who have formulated a central organizing principle of therapy will be
more effective and consistent in making therapeutic interventions.
The Model-Setting Participant
Leaders shape group norms not only through explicit or implicit social engineering but
also through the example they set in their own group behavior. 10 The therapy group
culture represents a radical departure from the social rules to which clients are
accustomed. Clients are asked to discard familiar social conventions, to try out new
behavior, and to take many risks. How can therapists best demonstrate to their clients that
new behavior will not have the anticipated adverse consequences?
One method, which has considerable research backing, is modeling: Clients are
encouraged to alter their behavior by observing their therapists engaging freely and
without adverse effects in the desired behavior. Bandura has demonstrated in many well-
controlled studies that individuals may be influenced to engage in more adaptive behavior
(for example, the overcoming of specific phobias)11 or less adaptive behavior (for
example, unrestrained aggressivity)12 through observing and assuming other’s behavior.
The leader may, by offering a model of nonjudgmental acceptance and appreciation of
others’ strengths as well as their problem areas, help shape a group that is health oriented.
If, on the other hand, leaders conceptualize their role as that of a detective of
psychopathology, the group members will follow suit. For example, one group member
had actively worked on the problems of other members for months but had steadfastly
declined to disclose her own problems. Finally in one meeting she confessed that one year

earlier she had had a two-month stay in a state psychiatric hospital. The therapist
responded reflexively, “Why haven’t you told us this before?”
This comment, perceived as punitive by the client, served only to reinforce her fear and
discourage further self-disclosure. Obviously, there are questions and comments that will
close people down and others that will help them open up. The therapist had “opening-up”
options: for example, “I think it’s great that you now trust the group sufficiently to share
these facts about yourself,” or, “How difficult it must have been for you in the group
previously, wanting to share this disclosure and yet being afraid to do so.”
The leader sets a model of interpersonal honesty and spontaneity but must also keep in
mind the current needs of the members and demonstrate behavior that is congruent with
those needs. Do not conclude that group therapists should freely express all feelings. Total
disinhibition is no more salubrious in therapy groups than in other forms of human
encounter and may lead to ugly, destructive interaction. The therapist must model
responsibility and appropriate restraint as well as honesty. We want to engage our clients
and allow ourselves to be affected by them. In fact, “disciplined personal involvement” is
an invaluable part of the group leader’s armamentarium.13 Not only is it therapeutic to our
clients that we let them matter to us, we can also use our own reactions as valuable data
about our clients—provided we know ourselves well enough.†
Consider the following therapeutically effective intervention:
• In the first session of a group of business executives meeting for a five-day human
relations laboratory, a twenty-five-year-old, aggressive, swaggering member who
had obviously been drinking heavily proceeded to dominate the meeting and make
a fool of himself. He boasted of his accomplishments, belittled the group,
monopolized the meeting, and interrupted, outshsituation—feedback about how
angry or hurt he had made others feel, or interpretations about the meaning and
cause of his behavior—failed. Then my co-leader commented sincerely, “You know
what I like about you? Your fear and lack of confidence. You’re scared here, just
like me. We’re all scared about what will happen to us this week.” That statement
permitted the client to discard his facade and, eventually, to become a valuable
group member. Furthermore, the leader, by modeling an empathic, nonjudgmental
style, helped establish a gentle, accepting group culture.
This effective intervention required that the co-leader first recognize the negative
impact of this member’s behavior and then supportively articulate the vulnerability that
lay beneath the offensive behavior.14
Interacting as a group member requires, among other things, that group therapists
accept and admit their personal fallibility. Therapists who need to appear infallible offer a
perplexing and obstructing example for their clients. At times they may be so reluctant to
admit error that they become withholding or devious in their relationship with the group.
For example, in one group, the therapist, who needed to appear omniscient, was to be out
of town for the next meeting. He suggested to the group members that they meet without
him and tape-record the meeting, and he promised to listen to the tape before the next

session. He forgot to listen to the tape but did not admit this to the group. Consequently,
the subsequent meeting, in which the therapist bluffed by avoiding mention of the
previous leaderless session, turned out to be diffuse, confusing, and discouraging.
Another example involves a neophyte therapist with similar needs. A group member
accused him of making long-winded, confusing statements. Since this was the first
confrontation of the therapist in this young group, the members were tense and perched on
the edge of their chairs. The therapist responded by wondering whether he didn’t remind
the client of someone from the past. The attacking member clutched at the suggestion and
volunteered his father as a candidate; the crisis passed, and the group members settled
back in their chairs. However, it so happened that previously this therapist had himself
been a member of a group (of psychotherapy students) and his colleagues had repeatedly
focused on his tendency to make long-winded, confusing comments. In fact, then, what
had transpired was that the client had seen the therapist quite correctly but was persuaded
to relinquish his perceptions. If one of the goals of therapy is to help clients test reality and
clarify their interpersonal relationships, then this transaction was antitherapeutic. This is
an instance in which the therapist’s needs were given precedence over the client’s needs in
psychotherapy.†
Another consequence of the need to be perfect occurs when therapists become overly
cautious. Fearing error, they weigh their words so carefully, interacting so deliberately that
they sacrifice spontaneity and mold a stilted, lifeless group. Often a therapist who
maintains an omnipotent, distant role is saying, in effect, “Do what you will; you can’t
hurt or touch me.” This pose may have the counterproductive effect of aggravating a sense
of interpersonal impotence in clients that impedes the development of an autonomous
group.
• In one group a young man named Les had made little movement for months
despite vigorous efforts by the leader. In virtually every meeting the leader
attempted to bring Les into the discussion, but to no avail. Instead, Les became
more defiant and withholding, and the therapist became more active and insistent.
Finally Joan, another member, commented to the therapist that he was like a
stubborn father treating Les like a stubborn son and was bound and determined to
make Les change. Les, she added, was relishing the role of the rebellious son who
was determined to defeat his father. Joan’s comment rang true for the therapist; it
clicked with his internal experience, and he acknowledged this to the group and
thanked Joan for her comments.
The therapist’s behavior in this example was extremely important for the group. In
effect, he said, I value you the members, this group, and this mode of learning.
Furthermore, he reinforced norms of self-exploration and honest interaction with the
therapist. The transaction was helpful to the therapist (unfortunate are the therapists who
cannot learn more about themselves in their therapeutic work) and to Les, who proceeded
to explore the payoff in his defiant stance toward the therapist.
Occasionally, less modeling is required of the therapist because of the presence of some
ideal group members who fulfill this function. In fact, there have been studies in which

selected model-setting members were deliberately introduced into a group.15 In one study,
researchers introduced trained confederates (not clients but psychology graduate students)
into two outpatient groups.16 The plants pretended to be clients but met regularly in group
discussions with the therapists and supervisors. Their role and behavior were planned to
facilitate, by their personal example, self-disclosure, free expression of affect,
confrontation with the therapists, silencing of monopolists, clique busting, and so on. The
two groups were studied (through participant-administered cohesiveness questionnaires
and sociometrics) for twenty sessions. The results indicated that the plants, though not the
most popular members, were regarded by the other participants as facilitating therapy;
moreover, the authors concluded (though there were no control groups) that the plants
served to increase group cohesiveness.
Although a trained plant would contribute a form of deceit incompatible with the
process of group therapy, the use of such individuals has intriguing clinical implications.
For example, a new therapy group could be seeded with an ideal group therapy member
from another group, who then continued therapy in two groups. Or an individual who had
recently completed group therapy satisfactorily might serve as a model-setting auxiliary
therapist during the formative period of a new group. Perhaps an ongoing group might
choose to add new members in advance of the graduation of senior members, rather than
afterward, to capitalize on the modeling provided by the experienced and successful senior
members.
These possibilities aside, it is the therapist who, wittingly or unwittingly, will continue
to serve as the chief model-setting figure for the group members. Consequently, it is of the
utmost importance that the therapist have sufficient self-confidence to fulfill this function.
If therapists feel uncomfortable, they will be more likely to encounter difficulties in this
aspect of their role and will often veer to one extreme or the other in their personal
engagement in the group: either they will fall back into a comfortable, concealed
professional role, or they will escape from the anxiety and responsibility inherent in the
leader’s role by abdicating and becoming simply one of the gang.†17
Neophyte therapists are particularly prone to these positions of exaggerated activity or
inactivity in the face of the emotional demands of leading therapy groups. Either extreme
has unfortunate consequences for the development of group norms. An overly concealed
leader will create norms of caution and guardedness. A therapist who retreats from
authority will be unable to use the wide range of methods available for the shaping of
norms; furthermore, such a therapist creates a group that is unlikely to work fruitfully on
important transference issues.
The issue of the transparency of the therapist has implications far beyond the task of
norm setting.† When therapists are self-disclosing in the group, not only do they model
behavior, but they perform an act that has considerable significance in many other ways
for the therapeutic process. Many clients develop conflicted and distorted feelings toward
the therapist; the transparency of the therapist facilitates members working through their
transference. I shall discuss the ramifications of therapist transparency in great detail in
chapter 7. Let us turn now from this general discussion of norms to the specific norms that

enhance the power of group therapy.
EXAMPLES OF THERAPEUTIC GROUP NORMS
The Self-Monitoring Group
It is important that the group begin to assume responsibility for its own functioning. If this
norm fails to develop, a passive group ensues, whose members are dependent on the
leader to supply movement and direction. The leader of such a group, who feels fatigued
and irritated by the burden of making everything work, is aware that something has gone
awry in the early development of the group. When I lead groups like this, I often
experience the members of the group as moviegoers. It’s as though they visit the group
each week to see what’s playing; if it happens to interest them, they become engaged in
the meeting. If not, “Too bad, Irv! Hope there’ll be a better show next week!” My task in
the group then is to help members understand that they are the movie. If they do not
perform, there is no performance: the screen is blank.
From the very beginning, I attempt to transfer the responsibility of the group to the
members. I keep in mind that in the beginning of a group, I am the only one in the room
who has a good definition of what constitutes a good work meeting. It is my job to teach
the members, to share that definition with them. Thus, if the group has a particularly good
meeting, I like to label it so. For example, I might comment at the end, “It’s time to stop.
It’s too bad, I hate to bring a meeting like this to an end.” In future meetings, I often make
a point of referring back to that meeting. In a young group, a particularly hard working
meeting is often followed by a meeting in which the members step back a bit from the
intensive interaction. In such a meeting, I might comment after a half hour, “I wonder how
everyone feels about the meeting today? How would you compare it with last week’s
meeting? What did we do differently last week?”
It is also possible to help members develop a definition of a good meeting by asking
them to examine and evaluate parts of a single meeting. For example, in the very early
meetings of a group, I may interrupt and remark, “I see that an hour has gone by and I’d
like to ask, ‘How has the group gone today? Are you satisfied with it? What’s been the
most involving part of the meeting so far today? The least involving part?’” The general
point is clear: I endeavor to shift the evaluative function from myself to the group
members. I say to them, in effect, “You have the ability—and responsibility—to determine
when this group is working effectively and when it is wasting its time.”
If a member laments, for example, that “the only involving part of this meeting was the
first ten minutes—after that we just chatted for forty-five minutes,” my response is: “Then
why did you let it go on? How could you have stopped it?” Or, “All of you seemed to have
known this. What prevented you from acting? Why is it always my job to do what you are
all able to do?” Soon there will be excellent consensus about what is productive and

unproductive group work. (And it will almost invariably be the case that productive work
occurs when the group maintains a here-and-now focus—to be discussed in the next
chapter.)
Self-Disclosure
Group therapists may disagree about many aspects of the group therapeutic procedure, but
there is great consensus about one issue: self-disclosure is absolutely essential in the group
therapeutic process. Participants will not benefit from group therapy unless they self-
disclose and do so fully. I prefer to lead a group with norms that indicate that self-
disclosure must occur—but at each member’s own pace. I prefer that members not
experience the group as a forced confessional, where deep revelations are wrung from
members one by one.18
During pregroup individual meetings, I make these points explicit to clients so that they
enter the group fully informed that if they are to benefit from therapy, sooner or later they
must share very intimate parts of themselves with the other group members.
Keep in mind that it is the subjective aspect of self-disclosure that is truly important.
There may be times when therapists or group observers will mistakenly conclude that the
group is not truly disclosing or that the disclosure is superficial or trivial. Often there is an
enormous discrepancy between subjective and objective self-disclosure—a discrepancy
that, incidentally, confounds research that measures self-disclosure on some standardized
scale. Many group therapy members have had few intimate confidantes, and what appears
in the group to be minor self-disclosure may be the very first time they have shared this
material with anyone. The context of each individual’s disclosure is essential in
understanding its significance. Being aware of that context is a crucial part of developing
empathy, as the following example illustrates.
• One group member, Mark, spoke slowly and methodically about his intense social
anxiety and avoidance. Marie, a young, bitter, and chronically depressed woman
bristled at the long and labored elaboration of his difficulties. At one point she
wondered aloud why others seemed to be so encouraging of Mark and excited
about his speaking, whereas she felt so impatient with the slow pace of the group.
She was concerned that she could not get to her personal agenda: to get advice
about how to make herself more likable. The feedback she received surprised her:
the members felt alienated from her because of her inability to empathize with
others. What was happening in the meeting with Mark was a case in point, they
told her. They felt that Mark’s self-disclosure in the meeting was a great step
forward for him. What interfered with her seeing what others saw? That was the
critical question. And exploring that difficulty was the “advice” the group offered.
What about the big secret? A member may come to therapy with an important secret
about some central aspect of his or her life—for example, compulsive shoplifting, secret
substance abuse, a jail sentence earlier in life, bulimia, transvestism, incest. They feel

trapped. Though they wish to work in the therapy group, they are too frightened to share
their secret with a large group of people.
In my pregroup individual sessions, I make it clear to such clients that sooner or later
they will have to share the secret with the other group members. I emphasize that they
may do this at their own pace, that they may choose to wait until they feel greater trust in
the group, but that, ultimately, the sharing must come if therapy is to proceed. Group
members who decide not to share a big secret are destined merely to re-create in the group
the same duplicitous modes of relating to others that exist outside the group. To keep the
secret hidden, they must guard every possible avenue that might lead to it. Vigilance and
guardedness are increased, spontaneity is decreased, and those bearing the secret spin an
ever-expanding web of inhibition around themselves.
Sometimes it is adaptive to delay the telling of the secret. Consider the following two
group members, John and Charles. John had been a transvestite since the age of twelve
and cross-dressed frequently but secretly. Charles entered the group with cancer. He stated
that he had done a lot of work learning to cope with his cancer. He knew his prognosis: he
would live for two or three more years. He sought group therapy in order to live his
remaining life more fully. He especially wanted to relate more intimately with the
important people in his life. This seemed like a legitimate goal for group therapy, and I
introduced him into a regular outpatient therapy group. (I have fully described this
individual’s course of treatment elsewhere.19)
Both of these clients chose not to disclose their secrets for many sessions. By that time I
was getting edgy and impatient. I gave them knowing glances or subtle invitations.
Eventually each became fully integrated into the group, developed a deep trust in the other
members, and, after about a dozen meetings, chose to reveal himself very fully. In
retrospect, their decision to delay was a wise one. The group members had grown to know
each of these two members as people, as John and Charles, who were faced with major
life problems, not as a transvestite and a cancer patient. John and Charles were justifiably
concerned that if they revealed themselves too early, they would be stereotyped and that
the stereotype would block other members from knowing them fully.
How can the group leader determine whether the client’s delay in disclosure is
appropriate or countertherapeutic? Context matters. Even though there has been no full
disclosure, is there, nonetheless, movement, albeit slow, toward increasing openness and
trust? Will the passage of time make it easier to disclose, as happened with John and
Charles, or will tension and avoidance mount?
Often hanging on to the big secret for too long may be counterproductive. Consider the
following example:
• Lisa, a client in a six-month, time-limited group, who had practiced for a few
years as a psychologist (after having trained with the group leader!) but fifteen
years earlier had given up her practice to enter the business world, where she soon
became extraordinarily successful. She entered the group because of
dissatisfaction with her social life. Lisa felt lonely and alienated. She knew that
she, as she put it, played her cards “too close to the vest”—she was cordial to

others and a good listener but tended to remain distant. She attributed this to her
enormous wealth, which she felt she must keep concealed so as not to elicit envy
and resentment from others.
By the fifth month, Lisa had yet to reveal much of herself. She retained her
psychotherapeutic skills and thus proved helpful to many members, who admired
her greatly for her unusual perceptiveness and sensitivity. But she had replicated
her outside social relationships in the here-and-now of the group, since she felt
hidden and distant from the other members. She requested an individual session
with the group leader to discuss her participation in the group. During that session
the therapist exhorted Lisa to reveal her concerns about her wealth and,
especially, her psychotherapy training, warning her that if she waited too much
longer, someone would throw a chair at her when she finally told the group she
had once been a therapist. Finally, Lisa took the plunge and ultimately, in the very
few remaining meetings, did more therapeutic work than in all the earlier meetings
combined.
What stance should the therapist take when someone reveals the big secret? To answer
that question, I must first make an important distinction. I believe that when an individual
reveals the big secret, the therapist must help him or her disclose even more about the
secret but in a horizontal rather than a vertical mode. By vertical disclosure I refer to
content, to greater in-depth disclosure about the secret itself. For example, when John
disclosed his transvestism to the group, the members’ natural inclination was to explore
the secret vertically. They asked about details of his crossdressing: “How old were you
when you started?” “Whose underclothes did you begin to wear?” “What sexual fantasies
do you have when you cross-dress?” “How do you publicly pass as a woman with that
mustache?” But John had already disclosed a great deal vertically about his secret, and it
was more important for him now to reveal horizontally: that is, disclosure about the
disclosure (metadisclosure)—especially about the interactional aspects of disclosure.20
Accordingly, when John first divulged his transvestism in the group I asked such
questions as: “John, you’ve been coming to the group for approximately twelve meetings
and not been able to share this with us. I wonder what it’s been like for you to come each
week and remain silent about your secret?” “How uncomfortable have you been about the
prospect of sharing this with us?” “It hasn’t felt safe for you to share this before now.
Today you chose to do so. What’s happened in the group or in your feelings toward the
group today that’s allowed you to do this?” “What were your fears in the past about
revealing this to us? What did you think would happen? Whom did you feel would
respond in which ways?”
John responded that he feared he would be ridiculed or laughed at or thought weird. In
keeping with the here-and-now inquiry, I guided him deeper into the interpersonal process
by inquiring, “Who in the group would ridicule you?” “Who would think you were
weird?” And then, after John selected certain members, I invited him to check out those
assumptions with them. By welcoming the belated disclosure, rather than criticizing the
delay, the therapist supports the client and strengthens the therapeutic collaboration. As a

general rule, it is always helpful to move from general statements about the “group” to
more personal statements: in other words, ask members to differentiate between the
members of the group.
Self-disclosure is always an interpersonal act. What is important is not that one
discloses oneself but that one discloses something important in the context of a
relationship to others. The act of self-disclosure takes on real importance because of its
implications for the nature of ongoing relationships; even more important than the actual
unburdening of oneself is the fact that disclosure results in a deeper, richer, and more
complex relationship with others. (This is the reason why I do not, in contrast to other
researchers,† consider self-disclosure as a separate therapeutic factor but instead subsume
it under interpersonal learning.)
The disclosure of sexual abuse or incest is particularly charged in this way. Often
victims of such abuse have been traumatized not only by the abuse itself but also by the
way others have responded in the past to their disclosure of the abuse. Not uncommonly
the initial disclosure within the victim’s family is met with denial, blame, and rejection. As
a result, the thought of disclosing oneself in the therapy group evokes fear of further
mistreatment and even retraumatization rather than hope of working through the abuse.21
If undue pressure is placed on a member to disclose, I will, depending on the problems
of the particular client and his or her stage of therapy, respond in one of several ways. For
example, I may relieve the pressure by commenting: “There are obviously some things
that John doesn’t yet feel like sharing. The group seems eager, even impatient, to bring
John aboard, while John doesn’t yet feel safe or comfortable enough.” (The word “yet” is
important, since it conveys the appropriate expectational set.) I might proceed by
suggesting that we examine the unsafe aspects of the group, not only from John’s
perspective but from other members’ perspectives as well. Thus I shift the emphasis of the
group from wringing out disclosures to exploring the obstacles to disclosure. What
generates the fear? What are the anticipated dreaded consequences? From whom in the
group do members anticipate disapprobation?
No one should ever be punished for self-disclosure. One of the most destructive events
that can occur in a group is for members to use personal, sensitive material, which has
been trustingly disclosed in the group, against one another in times of conflict. The
therapist should intervene vigorously if this occurs; not only is it dirty fighting, but it
undermines important group norms. This vigorous intervention can take many forms. In
one way or another, the therapist must call attention to the violation of trust. Often I will
simply stop the action, interrupt the conflict, and point out that something very important
has just happened in the group. I ask the offended member for his or her feelings about the
incident, ask others for theirs, wonder whether others have had similar experiences, point
out how this will make it difficult for others to reveal themselves, and so on. Any other
work in the group is temporarily postponed. The important point is that the incident be
underscored to reinforce the norm that self-disclosure is not only important but safe. Only
after the norm has been established should we turn to examine other aspects of the
incident.

Procedural Norms
The optimal procedural format in therapy is that the group be unstructured, spontaneous,
and freely interacting. But such a format never evolves naturally: much active culture
shaping is required on the part of the therapist. There are many trends the therapist must
counter. The natural tendency of a new group is to devote an entire meeting to each of the
members in rotation. Often the first person to speak or the one who presents the most
pressing life crisis that week obtains the group floor for the meeting. Some groups have
enormous difficulty changing the focus from one member to another, because a procedural
norm has somehow evolved whereby a change of topic is considered bad form, rude, or
rejecting. Members may lapse into silence: they feel they dare not interrupt and ask for
time for themselves, yet they refuse to keep the other member supplied with questions
because they hope, silently, that he or she will soon stop talking.
These patterns hamper the development of a potent group and ultimately result in group
frustration and discouragement. I prefer to deal with these antitherapeutic norms by calling
attention to them and indicating that since the group has constructed them, it has the
power to change them.
For example, I might say, “I’ve been noticing that over the past few sessions the entire
meeting has been devoted to only one person, often the first one who speaks that day, and
also that others seem unwilling to interrupt and are, I believe, sitting silently on many
important feelings. I wonder how this practice ever got started and whether or not we want
to change it.” A comment of this nature may be liberating to the group. The therapist has
not only given voice to something that everyone knows to be true but has also raised the
possibility of other procedural options.
Some groups evolve a formal “check-in” format in which each member in turn gets the
floor to discuss important events of the previous week or certain moments of great
distress. Sometimes, especially with groups of highly dysfunctional, anxious members,
such an initial structure is necessary and facilitating but, in my experience, such a formal
structure in most groups generally encourages an inefficient, taking-turns, noninteractive,
“then-and-there” meeting. I prefer a format in which troubled members may simply
announce at the beginning, “I want some time today,” and the members and the therapist
attempt, during the natural evolution of the session, to turn to each of those members.
Specialized groups, especially those with brief life spans and more deeply troubled
members, often require different procedural norms. Compromises must be made for the
sake of efficient time management, and the leader must build in an explicit structure. I will
discuss such modifications of technique in chapter 15 but for now wish only to emphasize
the general principle that the leader must attempt to structure a group in such a way as to
build in the therapeutic norms I discuss in this chapter: support and confrontation, self-
disclosure, self-monitoring, interaction, spontaneity, the importance of the group members
as the agents of help.
The Importance of the Group to Its Members

The more important the members consider the group, the more effective it becomes. I
believe that the ideal therapeutic condition is present when clients consider their therapy
group meeting to be the most important event in their lives each week. The therapist is
well advised to reinforce this belief in any available manner. If I am forced to miss a
meeting, I inform the members well in advance and convey to them my concern about my
absence. I arrive punctually for meetings. If I have been thinking about the group between
sessions, I may share some of these thoughts with the members. Any self-disclosures I
make are made in the service of the group. Though some therapists eschew such personal
disclosure, I believe that it is important to articulate how much the group matters to you.
I reinforce members when they give testimony of the group’s usefulness or when they
indicate that they have been thinking about other members during the week. If a member
expresses regret that the group will not meet for two weeks over the Christmas holidays, I
urge them to express their feelings about their connection to the group. What does it mean
to them to cherish the group? To protest its disruption? To have a place in which to
describe their concerns openly rather than submerge their longings?
The more continuity between meetings, the better. A well-functioning group continues
to work through issues from one meeting to the next. The therapist does well to encourage
continuity. More than anyone else, the therapist is the group historian, connecting events
and fitting experiences into the temporal matrix of the group. “That sounds very much like
what John was working on two weeks ago,” or, “Ruthellen, I’ve noticed that ever since
you and Debbie had that run-in three weeks ago, you have become more depressed and
withdrawn. What are your feelings now toward Debbie?”
I rarely start a group meeting, but when I do, it is invariably in the service of providing
continuity between meetings. Thus, when it seems appropriate, I might begin a meeting:
“The last meeting was very intense! I wonder what types of feelings you took home from
the group and what those feelings are now?”
In chapter 14, I will describe the group summary, a technique that serves to increase the
sense of continuity between meetings. I write a detailed summary of the group meeting
each week (an editorialized narrative description of content and process) and mail it to the
members between sessions. One of the many important functions of the summary is that it
offers the client another weekly contact with the group and increases the likelihood that
the themes of a particular meeting will be continued in the following one.
The group increases in importance when members come to recognize it as a rich
reservoir of information and support. When members express curiosity about themselves,
I, in one way or another, attempt to convey the belief that any information members might
desire about themselves is available in the group room, provided they learn how to tap it.
Thus, when Ken wonders whether he is too dominant and threatening to others, my reflex
is to reply, in effect, “Ken, there are many people who know you very well in this room.
Why not ask them?”
Events that strengthen bonds between members enhance the potency of the group. It
bodes well when group members go out for coffee after a meeting, hold long discussions
in the parking lot, or phone one another during the week in times of crisis. (Such

extragroup contact is not without potential adverse effects, as I shall discuss in detail in
chapter 11.)
Members as Agents of Help
The group functions best if its members appreciate the valuable help they can provide one
another. If the group continues to regard the therapist as the sole source of aid, then it is
most unlikely that the group will achieve an optimal level of autonomy and self-respect.
To reinforce this norm, the therapist may call attention to incidents demonstrating the
mutual helpfulness of members. The therapist may also teach members more effective
methods of assisting one another. For example, after a client has been working with the
group on some issue for a long portion of a meeting, the therapist may comment, “Reid,
could you think back over the last forty-five minutes? Which comments have been the
most helpful to you and which the least?” Or, “Victor, I can see you’ve been wanting to
talk about that for a long time in the group and until today you’ve been unable to.
Somehow Eve helped you to open up. What did she do? And what did Ben do today that
seemed to close you down rather than open you up?” Behavior undermining the norm of
mutual helpfulness should not be permitted to go unnoticed. If, for example, one member
challenges another concerning his treatment of a third member, stating, “Fred, what right
do you have to talk to Peter about that? You’re a hell of a lot worse off than he is in that
regard,” I might intervene by commenting, “Phil, I think you’ve got some negative
feelings about Fred today, perhaps coming from another source. Maybe we should get into
them. I can’t, however, agree with you when you say that because Fred is similar to Peter,
he can’t be helpful. In fact, quite the contrary has been true here in the group.”
Support and Confrontation
As I emphasized in my discussion of cohesiveness, it is essential that the members
perceive their therapy group as safe and supportive. Ultimately, in the course of therapy,
many uncomfortable issues must be broached and explored. Many clients have problems
with rage or are arrogant or condescending or insensitive or just plain cantankerous. The
therapy group cannot offer help without such traits emerging during the members’
interactions. In fact, their emergence is to be welcomed as a therapeutic opportunity.
Ultimately, conflict must occur in the therapy group, and, as I will discuss in chapter 12, it
is essential for the work of therapy. At the same time, however, too much conflict early in
the course of a group can cripple its development. Before members feel free enough to
express disagreement, they must feel safe enough and must value the group highly enough
to be willing to tolerate uncomfortable meetings.
Thus, the therapist must build a group with norms that permit conflict but only after
firm foundations of safety and support have been established. It is often necessary to
intervene to prevent the proliferation of too much conflict too early in the group, as the
following incident illustrates.

• In a new therapy group, there were two particularly hostile members, and by the
third meeting there was considerable open carping, sarcasm, and conflict. The
fourth meeting was opened by Estelle (one of these two members), emphasizing
how unhelpful the group had been to her thus far. Estelle had a way of turning
every positive comment made to her into a negative, combative one. She
complained, for example, that she could not express herself well and that there
were many things she wanted to say but she was so inarticulate she couldn’t get
them across.
When another member of the group disagreed and stated that she found Estelle to
be extremely articulate, Estelle challenged the other member for doubting her
judgment about herself. Later in the group, she complimented another member by
stating, “Ilene, you’re the only one here who’s ever asked me an intelligent
question.” Obviously, Ilene was made quite uncomfortable by this hexed
compliment.
At this point I felt it was imperative to challenge the norms of hostility and
criticism that had developed in the group, and intervened forcefully. I asked
Estelle: “What are your guesses about how your statement to Ilene makes others in
the group feel?”
Estelle hemmed and hawed but finally offered that they might possibly feel
insulted. I suggested that she check that out with the other members of the group.
She did so and learned that her assumption was correct. Not only did every
member of the group feel insulted, but Ilene also felt irritated and put off by the
statement. I then inquired, “Estelle, it looks as though you’re correct. You did
insult the group. Also it seems that you knew that this was likely to occur. But
what’s puzzling is the payoff for you. What do you get out of it?”
Estelle suggested two possibilities. First she said, “I’d rather be rejected for
insulting people than for being nice to them.” That seemed a piece of twisted logic
but nonetheless comprehensible. Her second statement was: “At least this way I
get to be the center of attention.” “Like now?” I asked. She nodded. “How does it
feel right now?” I wondered. Estelle said, “It feels good.” “How about the rest of
your life?” I asked. She responded ingenuously, “It’s lonely. In fact, this is it. This
hour and a half is the people in my life.” I ventured, “Then this group is a really
important place for you?” Estelle nodded. I commented, “Estelle, you’ve always
stated that one of the reasons you’re critical of others in the group is that there’s
nothing more important than total honesty. If you want to be absolutely honest with
us, however, I think you’ve got to tell us also how important we are to you and how
much you like being here. That you never do, and I wonder if you can begin to
investigate why it is so painful or dangerous for you to show others here how
important they are to you.”
By this time Estelle had become much more conciliatory and I was able to
obtain more leverage by enlisting her agreement that her hostility and insults did
constitute a problem for her and that it would help her if we called her on it—that

is, if we instantaneously labeled any insulting behavior on her part. It is always
helpful to obtain this type of contract from a member: in future meetings, the
therapist can confront members with some particular aspect of their behavior that
they have asked to be called to their attention. Since they experience themselves as
allies in this spotting and confrontative process, they are far less likely to feel
defensive about the intervention.
Many of these examples of therapist behavior may seem deliberate, pedantic, even
pontifical. They are not the nonjudgmental, nondirective, mirroring, or clarifying
comments typical of a therapist’s behavior in other aspects of the therapeutic process. It is
vital, however, that the therapist attend deliberately to the tasks of group creation and
culture building. These tasks underlie and, to a great extent, precede much of the other
work of the therapist.
It is time now to turn to the third basic task of the therapist: the activation and
illumination of the here-and-now.

Chapter 6
THE THERAPIST: WORKING IN THE HERE – AND – NOW
The major difference between a psychotherapy group that hopes to effect extensive and
enduring behavioral and characterological change and such groups as AA,
psychoeducational groups, cognitive-behavioral groups, and cancer support groups is that
the psychotherapy group strongly emphasizes the importance of the here-and-now
experience. Yet all group therapies, including highly structured groups, benefit from the
group therapist’s capacity to recognize and understand the here-and-now. Therapists who
are aware of the nuances of the relationships between all the members of the group are
more adept at working on the group task even when deeper group and interpersonal
exploration or interpretation is not the therapy focus.1
In chapter 2, I presented some of the theoretical underpinnings of the use of the here-
and-now. Now it is time to focus on the clinical application of the here-and-now in group
therapy. First, keep in mind this important principle—perhaps the single most important
point I make in this entire book: the here-and-now focus, to be effective, consists of two
symbiotic tiers, neither of which has therapeutic power without the other.
The first tier is an experiencing one: the members live in the here-and-now; they
develop strong feelings toward the other group members, the therapist, and the group.
These here-and-now feelings become the major discourse of the group. The thrust is
ahistorical: the immediate events of the meeting take precedence over events both in the
current outside life and in the distant past of the members. This focus greatly facilitates
the development and emergence of each member’s social microcosm. It facilitates
feedback, catharsis, meaningful self-disclosure, and acquisition of socializing techniques.
The group becomes more vital, and all of the members (not only the ones directly working
in that session) become intensely involved in the meeting.
But the here-and-now focus rapidly reaches the limits of its usefulness without the
second tier, which is the illumination of process. If the powerful therapeutic factor of
interpersonal learning is to be set in motion, the group must recognize, examine, and
understand process. It must examine itself; it must study its own transactions; it must
transcend pure experience and apply itself to the integration of that experience.
Thus, the effective use of the here-and-now requires two steps: the group lives in the
here-and-now, and it also doubles back on itself; it performs a self-reflective loop and
examines the here-and-now behavior that has just occurred.
If the group is to be effective, both aspects of the here-and-now are essential. If only the
first—the experiencing of the here-and-now—is present, the group experience will still be
intense, members will feel deeply involved, emotional expression may be high, and
members will finish the group agreeing, “Wow, that was a powerful experience!” Yet it
will also prove to be an evanescent experience: members will have no cognitive
framework that will permit them to retain the group experience, to generalize from it, to

identify and alter their interpersonal behavior, and to transfer their learning from the group
to situations back home. This is precisely the error made by many encounter group leaders
of earlier decades.
If, on the other hand, only the second part of the here-and-now—the examination of
process—is present, then the group loses its liveliness and meaningfulness. It degenerates
into a sterile intellectual exercise. This is the error made by overly formal, aloof, rigid
therapists.
Accordingly, the therapist has two discrete functions in the here-and-now: to steer the
group into the here-and-now and to facilitate the self-reflective loop (or process
commentary). Much of the here-and-now steering function can be shared by the group
members, but for reasons I will discuss later, process commentary remains to a large
extent the task of the therapist.
The majority of group therapists understand that their emphasis must be on the here-
and-now. A large survey of seasoned group therapists underscored activation of the here-
and-now as a core skill of the contemporary group therapist.2 A smaller but careful study
codified group therapists’ interpretations and found that over 60 percent of interpretations
focused on the here-and-now (either behavioral patterns or impact of behavior), while
approximately 20 percent focused on historical causes and 20 percent on motivation.3
DEFINITION OF PROCESS
The term process, used liberally throughout this text, has a highly specialized meaning in
many fields, including law, anatomy, sociology, anthropology, psychoanalysis, and
descriptive psychiatry. In interactional psychotherapy, too, process has a specific technical
meaning: it refers to the nature of the relationship between interacting individuals—
members and therapists. Moreover, as we shall see, a full understanding of process must
take into account a large number of factors, including the internal psychological worlds of
each member, interpersonal interactions, group-as-a-whole forces, and the clinical
environment of the group.†4
It is useful to contrast process with content. Imagine two individuals in a discussion.
The content of that discussion consists of the explicit words spoken, the substantive issues,
the arguments advanced. The process is an altogether different matter. When we ask about
process, we ask, “What do these explicit words, the style of the participants, the nature of
the discussion, tell about the interpersonal relationship of the participants?”
Therapists who are process-oriented are concerned not primarily with the verbal content
of a client’s utterance, but with the “how” and the “why” of that utterance, especially
insofar as the how and the why illuminate aspects of the client’s relationship to other
people. Thus, therapists focus on the metacommunicationall aspects of the message and
wonder why, from the relationship aspect, an individual makes a statement at a certain

time in a certain manner to a certain person. Some of the message’s impact is conveyed
verbally and directly; some of the message is expressed paraverbally (by nuance,
inflection, pitch, and tone); and some of the message is expressed behaviorally.†
Identifying the connection between the communication’s actual impact and the
communicator’s intent is at the heart of the therapy process.
Consider, for example, this transaction: During a lecture, a student raised her hand and
asked what year did Freud die? The lecturer replied, “1938,” only to have the student
inquire, “But, sir, wasn’t it 1939?” Since the student asked a question whose answer she
already knew, her motivation was obviously not a quest for information. (A question isn’t
a question if you know the answer.) The process of this transaction? Most likely that the
student wished to demonstrate her knowledge or wished to humiliate or defeat the
lecturer!
Frequently, the understanding of process in a group is more complex than in a two-
person interaction; we must search for the process not only behind a simple statement but
behind a sequence of statements made by several members. The group therapist must
endeavor to understand what a particular sequence reveals about the relationship between
one client and the other group members, or between clusters or cliques of members, or
between the members and the leader, or, finally, between the group as a whole and its
primary task.†
Some clinical vignettes may further clarify the concept.
• Early in the course of a group therapy meeting, Burt, a tenacious, intense,
bulldog-faced graduate student, exclaimed to the group in general and to Rose (an
unsophisticated, astrologically inclined cosmetologist and mother of four) in
particular, “Parenthood is degrading!” This provocative statement elicited
considerable response from the group members, all of whom had parents and many
of whom were parents. The free-for-all that followed consumed the remainder of
the group session.
Burt’s statement can be viewed strictly in terms of content. In fact, this is precisely what
occurred in the group; the members engaged Burt in a debate over the virtues versus the
dehumanizing aspects of parenthood—a discussion that was affect-laden but
intellectualized and brought none of the members closer to their goals in therapy.
Subsequently, the group felt discouraged about the meeting and angry with themselves and
with Burt for having dissipated a meeting.
On the other hand, the therapist might have considered the process of Burt’s statement
from any one of a number of perspectives:
1. Why did Burt attack Rose? What was the interpersonal process between them? In
fact, the two had had a smoldering conflict for many weeks, and in the previous
meeting Rose had wondered why, if Burt was so brilliant, he was still, at the age of
thirty-two, a student. Burt had viewed Rose as an inferior being who functioned
primarily as a mammary gland; once when she was absent, he referred to her as a
brood mare.

2. Why was Burt so judgmental and intolerant of nonintellectuals? Why did he
always have to maintain his self-esteem by standing on the carcass of a vanquished
or humiliated adversary?
3. Assuming that Burt’s chief intent was to attack Rose, why did he proceed so
indirectly? Is this characteristic of Burt’s expression of aggression? Or is it
characteristic of Rose that no one dares, for some unclear reason, to attack her
directly?
4. Why did Burt, through an obviously provocative and indefensible statement, set
himself up for a universal attack by the group? Although the lyrics were different,
this was a familiar melody for the group and for Burt, who had on many previous
occasions placed himself in this position. Why? Was it possible that Burt was most
comfortable when relating to others in this fashion? He once stated that he had
always loved a fight; indeed, he glowed with anticipation at the appearance of a
quarrel in the group. His early family environment was distinctively a fighting one.
Was fighting, then, a form (perhaps the only available form) of involvement for
Burt?
5. The process may be considered from the even broader perspective of the entire
group. Other relevant events in the life of the group must be considered. For the
past two months, the session had been dominated by Kate, a deviant, disruptive,
and partially deaf member who had, two weeks earlier, dropped out of the group
with the face-saving proviso that she would return when she obtained a hearing
aid. Was it possible that the group needed a Kate, and that Burt was merely filling
the required role of scapegoat?
Through its continual climate of conflict, through its willingness to spend an entire
session discussing in nonpersonal terms a single theme, was the group avoiding something
—possibly an honest discussion of members’ feelings about Kate’s rejection by the group
or their guilt or fear of a similar fate? Or were they perhaps avoiding the anticipated perils
of self-disclosure and intimacy? Was the group saying something to the therapist through
Burt (and through Kate)? For example, Burt may have been bearing the brunt of an attack
really aimed at the co-therapists but displaced from them. The therapists—aloof figures
with a proclivity for rabbinical pronouncements—had never been attacked or confronted
by the group. Their cotherapy relationship had also escaped any comment to date. Surely
there were strong, avoided feelings toward the therapists, which may have been further
fanned by their failure to support Kate and by their complicity through inactivity in her
departure from the group.
Which one of these many process observations is correct? Which one could the
therapists have employed as an effective intervention? The answer is, of course, that any
and all may be correct. They are not mutually exclusive; each views the transaction from a
slightly different vantage point. What is critical, however, is that the focus on process
begins with the therapist’s reflection on the host of factors that may underlie an
interaction. By clarifying each of these in turn, the therapist could have focused the group
on many different aspects of its life. Which one, then, should the therapist have chosen?

The therapist’s choice should be based on one primary consideration: the immediate
needs of the group. Where was the group at that particular time? The therapist had many
options. If he felt there had been too much focus on Burt of late, leaving the other
members feeling bored, uninvolved, and excluded, then he might have wondered aloud
what the group was avoiding. The therapist might have then reminded the group of
previous sessions spent in similar discussions that left them dissatisfied, or might have
helped one of the members verbalize this point by inquiring about the members’ inactivity
or apparent uninvolvement in the discussion. If he felt that the indirectness of the group
communication was a major issue he might have commented on the indirectness of Burt’s
attacks or asked the group to help clarify, via feedback, what was happening between Burt
and Rose. If he felt that an exceptionally important group event (Kate’s departure) was
being strongly avoided, then he might have focused on that event and the conspiracy of
silence around it.
In short, the therapist must determine what he or she thinks the group and its members
need most at a particular time and help it move in that direction.
• In another group, Saul sought therapy because of his deep sense of isolation. He
was particularly interested in a group therapeutic experience because he had
never before been a part of a primary group. Even in his primary family, he had
felt himself an outsider. He had been a spectator all his life, pressing his nose
against cold windowpanes, gazing longingly at warm, convivial groups within.
At Saul’s fourth therapy meeting, another member, Barbara, began the meeting
by announcing that she had just broken up with a man who had been very
important to her. Barbara’s major reason for being in therapy had been her
inability to sustain a relationship with a man, and she was profoundly distressed in
the meeting. Barbara had an extremely poignant way of describing her pain, and
the group was swept along with her feelings. Everyone in the group was very
moved; I noted silently that Saul, too, had tears in his eyes.
The group members (with the exception of Saul) did everything in their power to
offer Barbara support. They passed Kleenex; they reminded her of all her good
qualities and assets; they reassured her that she had made a wrong choice, that the
man was not good enough for her, that she was “lucky to be rid of that jerk.”
Suddenly Saul interjected, “I don’t like what’s going on here in the group today,
and I don’t like the way it’s being led” (a thinly veiled allusion to me, I thought).
He went on to explain that the group members had no justification for their
criticism of Barbara’s ex-boyfriend. They didn’t really know what he was like. They
could see him only through Barbara’s eyes, and probably she was presenting him
in a distorted way. (Saul had a personal ax to grind on this matter, having gone
through a divorce a couple of years earlier. His wife had attended a women’s
support group, and he had been the “jerk” of that group.)
Saul’s comments, of course, changed the entire tone of the meeting. The softness
and support disappeared. The room felt cold; the warm bond among the members
was broken. Everyone was on edge. I felt justifiably reprimanded. Saul’s position

was technically correct: the group was wrong to condemn Barbara’s ex-boyfriend
in such a sweeping and uncritical manner.
So much for the content. Now let’s examine the process of this interaction. First,
note that Saul’s comment had the effect of putting him outside the group. The rest
of the group was caught up in a warm, supportive atmosphere from which he
excluded himself. Recall his chief complaint that he was never a member of a
group, but always the outsider. The meeting provided an in vivo demonstration of
how that came to pass. In his fourth group meeting, Saul had, kamikaze-style,
attacked and voluntarily ejected himself from a group he wished to join.
A second issue had to do not with what Saul said but what he did not say. In the
early part of the meeting, everyone except Saul had made warm, supportive
statements to Barbara. I had no doubt that Saul felt supportive of her; the tears in
his eyes indicated that. Why had he chosen to be silent? Why did he always choose
to respond from his critical self and not from his warmer, more supportive self?
The examination of this aspect of the process led to some very important issues
for Saul. Obviously it was difficult for him to express the softer, affectionate part of
himself. He feared being vulnerable and exposing his dependent cravings. He
feared losing himself and his own uniqueness by getting too close to another and
by becoming a member of a group. Behind the aggressive, ever-vigilant, hard-
nosed defender of honesty (but a selective honesty: honesty of expression of
negative but not positive sentiments), there is often the softer, submissive child
thirsting for acceptance and love.

• In a T-group (an experiential training group) of clinical psychology interns, one
of the members, Robert, commented that he genuinely missed the contributions of
some of the members who had been generally very silent. He turned to two of these
members and asked if there was anything he or others could do that would help
them participate more. The two members and the rest of the group responded by
launching a withering attack on Robert. He was reminded that his own
contributions had not been substantial, that he was often silent for entire meetings
himself, that he had never really expressed his emotions in the group, and so forth.
Viewed at the content level, this transaction is bewildering: Robert expressed
genuine concern for the silent members and, for his solicitude, was soundly
buffeted. Viewed at the process—that is, relationship—level, however, it makes
perfectly good sense: the group members were much involved in a struggle for
dominance, and their inner response to Robert’s statement was, “Who are you to
issue an invitation to speak? Are you the host or leader here? If we allow you to
comment on our silence and suggest solutions, then we acknowledge your
dominion over us.”

• In another group, Kevin, an overbearing business executive, opened the meeting

by asking the other members—housewives, teachers, clerical workers, and
shopkeepers—for help with a problem: he had received “downsizing” orders. He
had to cut his staff immediately by 50 percent—to fire twenty of his staff of forty.
The content of the problem was intriguing, and the group spent forty-five
minutes discussing such aspects as justice versus mercy: that is, whether one
retains the most competent workers or workers with the largest families or those
who would have the greatest difficulty in finding other jobs. Despite the fact that
most of the members engaged animatedly in the discussion, which involved
important problems in human relations, the co-therapists regarded the session as
unproductive: it was impersonal, the members remained in safe territory, and the
discussion could have appropriately occurred at a dinner party or any other social
gathering. Furthermore, as time passed, it became abundantly clear that Kevin
had already spent considerable time thinking through all aspects of this problem,
and no one was able to provide him with novel approaches or suggestions. The
session was not truly a work session: instead it was a flight-from-work session.
Such a dedicated focus on content is inevitably frustrating for the group, and the
therapists began to wonder about process—that is, what this content revealed
about the nature of Kevin’s relationship to the other members. As the meeting
progressed, Kevin, on two occasions, let slip the amount of his salary (which was
more than double that of any other member). In fact, the overall interpersonal
effect of Kevin’s presentation was to make others aware of his affluence and power.
The process became even more clear when the therapists recalled the previous
meetings in which Kevin had attempted, in vain, to establish a special kind of
relationship with one of the therapists (he had sought some technical information
on psychological testing for personnel). Furthermore, in the preceding meeting,
Kevin had been soundly attacked by the group for his fundamentalist religious
convictions, which he used to criticize others’ behavior but not his own propensity
for extramarital affairs and compulsive lying. At that meeting, he had also been
termed “thick-skinned” because of his apparent insensitivity to others. However,
despite the criticism he had received, Kevin was a dominant member: he was the
most active and central figure in almost every meeting.
With this information about process, let’s examine the alternatives available to
consider. The therapists might have focused on Kevin’s bid for prestige, especially
after the attack on him and his loss of face in the previous meeting. Phrased in a
nonaccusatory manner, a clarification of this sequence might have helped Kevin
become aware of his desperate need for the group members to respect and admire
him. At the same time, the self-defeating aspects of his behavior could have been
pointed out. Despite his yearning for respect, the group had come to resent and at
times even to scorn him. Perhaps, too, Kevin was attempting to repudiate the
charge of being thick-skinned by sharing with the group in melodramatic fashion
the personal agony he experienced in deciding how to cut his staff.
The style of the therapists’ intervention would depend on Kevin’s degree of

defensiveness: if he had seemed particularly brittle or prickly, then the therapists
might have underscored how hurt he must have been at the previous meeting. If he
had been more open, they might have asked him directly what type of response he
would have liked from the others.
Other therapists might have preferred to interrupt the content discussion and
simply ask the group what Kevin’s question had to do with last week’s session. Still
another alternative would be to call attention to an entirely different type of
process by reflecting on the group’s apparent willingness to permit Kevin to occupy
center stage in the group week after week. By encouraging the members to discuss
their response to his monopolization, the therapist could have helped the group
initiate an exploration of their relationship with Kevin.
Keep in mind that therapists need not wait until they have all the answers before asking
a process question. Therapists may begin the process inquiry by simply asking the
members: “How are each of you experiencing the meeting so far?” Or they may use
slightly more inference: “You look like you are having some reaction to this.” At other
times, the therapist’s level of inference may be raised and interventions may be more
precise and interpretive: “Kevin, I have a sense that you yearn for respect here in the
group, and I wonder if the comment last week about you being ‘thick-skinned’ isn’t in
some way related to your bringing in this work dilemma.”
PROCESS FOCUS: THE POWER SOURCE OF THE
GROUP
The focus on process—on the here-and-now—is not just one of many possible procedural
orientations; on the contrary, it is indispensable and a common denominator of all
effective interactional groups. One so often hears words to this effect: “No matter what
else may be said about experiential groups (therapy groups, encounter groups, and so on),
one cannot deny that they are potent—that they offer a compelling experience for
participants.” Why are these groups potent? Precisely because they encourage process
exploration. The process focus is the power cell of the group.
A process focus is the one truly unique feature of the experiential group; after all, there
are many socially sanctioned activities in which one can express emotions, help others,
give and receive advice, confess and discover similarities between oneself and others. But
where else is it permissible, in fact encouraged, to comment, in depth, on here-and-now
behavior, on the nature of the immediately current relationship between people? Possibly
only in the parent–young child relationship, and even then the flow is unidirectional. The
parent, but not the child, is permitted process comments: “Don’t look away when I talk to
you!” “Be quiet when someone else is speaking.” “Stop saying, ‘I dunno.’”
Consider the cocktail party. Imagine confronting the narcissistic self-absorbed
individual who looks through or over you while talking to you, searching for someone

more attractive or appealing. In place of an authentic encounter, we are most likely to
comment, “Good talking with you …” or “I need to refill my drink …” The cocktail party
is not the place for process. Responding authentically and in a process-oriented fashion
would very likely thin out one’s party invitations.
Process commentary among adults is taboo social behavior; it is considered rude or
impertinent. Positive comments about another’s immediate behavior often denote a
seductive or flirtatious relationship. When an individual comments negatively about
another’s manners, gestures, speech, or physical appearance, we can be certain that the
battle is bitter and the possibility of conciliation chancy.
Why should this be so? What are the sources of this taboo? Miles, in a thoughtful
essay,5 suggests the following reasons that process commentary is eschewed in social
intercourse: socialization anxiety, social norms, fear of retaliation, and power
maintenance.
Socialization Anxiety
Process commentary evokes early memories and anxieties associated with parental
criticism of the child’s behavior. Parents comment on the behavior of children. Although
some of this process focus is positive, much more is critical and serves to control and alter
the child’s behavior. Adult process commentary often awakens old socialization-based
anxiety and is experienced as critical and controlling.
Social Norms
If individuals felt free to comment at all times on the behavior of others, social life would
become intolerably self-conscious, complex, and conflicted. Underlying adult interaction
is an implicit contract that a great deal of immediate behavior will be invisible to the
parties involved. Each party acts in the safety of the knowledge that one’s behavior is not
being noticed (or controlled) by the others; this safety provides an autonomy and a
freedom that would be impossible if each continuously dwelled on the fact that others
observe one’s behavior and are free to comment on it.
Fear of Retaliation
We cannot monitor or stare at another person too closely, because (unless the relationship
is exceedingly intimate) such intrusiveness is almost always dangerous and anxiety-
provoking and evokes retribution. There exist no forums, aside from such intentional
systems as therapy groups, for interacting individuals to test and to correct their
observations of one another.

Power Maintenance
Process commentary undermines arbitrary authority structure. Industrial organizational
development consultants have long known that an organization’s open investigation of its
own structure and process leads to power equalization—that is, a flattening of the
hierarchical pyramid. Generally, individuals high on the pyramid not only are more
technically informed but also possess organizational information that permits them to
influence and manipulate: that is, they not only have skills that have allowed them to
obtain a position of power but, once there, have such a central place in the flow of
information that they are able to reinforce their position. The more rigid the authority
structure of an organization, the more stringent are the precautions against open
commentary about process (as in, for example, the military or the church). The individual
who wishes to maintain a position of arbitrary authority is wise to inhibit the development
of any rules permitting reciprocal process observation and commentary.
In psychotherapy, process commentary involves a great degree of therapist
transparency, exposure, and even intimacy; hence many therapists resist this approach
because of their own uneasiness or anxiety. Moving into process means moving into
recognition that relationships are jointly created by both participants and has a mutual
impact.
THE THERAPIST’S TASKS IN THE HERE-AND-NOW
In the first stage of the here-and-now focus—the activating phase—the therapist’s task is
to move the group into the here-and-now. By a variety of techniques, many of which I will
discuss shortly, group leaders steer the group members away from outside material to
focus instead on their relationship with one another. Group therapists expend more time
and effort on this task early than late in the course of the group, because as the group
progresses, the members begin to share much of this task, and the here-and-now focus
often becomes an effortless and natural part of the group flow. In fact, many of the norms
described in the last chapter, which the therapist must establish in the group, foster a here-
and-now focus. For example, the leader who sets norms of interpersonal confrontation, of
emotional expressivity, of self-monitoring, of valuing the group as an important source of
information, is, in effect, reinforcing the importance of the here-and-now. Gradually
members, too, come to value the here-and-now and will themselves focus on it and, by a
variety of means, encourage their fellow members to do likewise.
It is altogether another matter with the second phase of the here-and-now orientation,
process illumination. Forces prevent members from fully sharing that task with the
therapist. Recall the T-group vignette presented earlier in which Robert commented on
process and thereby set himself apart from the other members and was viewed with
suspicion, as “not one of us.” When a group member makes observations about what is
happening in the group, the others often respond resentfully about the presumptuousness

of elevating himself or herself above the others.
If a member comments, for example, that “nothing is happening today,” or that “the
group is stuck,” or that “no one is self-revealing,” or that “there seem to be strong feelings
toward the therapist,” then that member is courting danger. The response of the other
members is predictable. They will challenge the challenging member: “You make
something happen today,” or “You reveal yourself,” or “You talk about your feelings
toward the therapist.” Only the therapist is relatively exempt from that charge. Only the
therapist has the right to suggest that others work or that others reveal themselves without
having to engage personally in the act he or she suggests.
Throughout the life of the group, the members are involved in a struggle for position in
the hierarchy of dominance. At times, the conflict around control and dominance is
flagrant; at other times, quiescent. But it never vanishes and should be explored in therapy
both because it is a rich source of material and also to prevent it from hardening into a
source of continuing, fractious conflict.
Some members strive nakedly for power; others strive subtly; others desire it but are
fearful of assertion; others always assume an obsequious, submissive posture. Statements
by members that suggest that they place themselves above or outside the group generally
evoke responses that emerge from the dominance struggle rather than from consideration
of the content of the statement. Even therapists are not entirely immune from evoking this
response; some clients are inordinately sensitive to being controlled or manipulated by the
therapist. They find themselves in the paradoxical position of applying to the therapist for
help and yet are unable to accept help because all statements by the therapist are viewed
through spectacles of distrust. This is a function of the specific pathology of some clients
(and it is, of course, good grist for the therapeutic mill). It is not a universal response of
the entire group.
The therapist is an observer-participant in the group. The observer status affords the
objectivity necessary to store information, to make observations about sequences or
cyclical patterns of behavior, to connect events that have occurred over long periods of
time. Therapists act as group historians. Only they are permitted to maintain a temporal
perspective; only they remain immune from the charge of not being one of the group, of
elevating themselves above the others. It is also only the therapists who keep in mind the
original goals of the group members and the relationship between these goals and the
events that gradually unfold in the group. The group therapist is the principal standard
bearer of the group culture, supporting and sustaining the group and pushing it forward in
its work.†6
• Two group members, Tim and Marjorie, had a sexual affair that eventually came
to light in the group. The other members reacted in various ways but none so
condemnatory nor so vehemently as Diana, a forty-five-year-old nouveau-moralist,
who criticized them both for breaking group rules: Tim, for “being too intelligent
to act like such a fool,” Marjorie for her “irresponsible disregard for her husband
and child,” and the Lucifer therapist (me) who “just sat there and let it happen.” I
eventually pointed out that, in her formidable moralistic broadside, some

individuals had been obliterated, that the Marjorie and Tim, with all their
struggles and doubts and fears, whom Diana had known for so long had suddenly
been replaced by faceless one-dimensional stereotypes. Furthermore, I was the
only one to recall, and to remind the group, of the reasons (expressed at the first
group meeting) why Diana had sought therapy: namely, that she needed help in
dealing with her rage toward a nineteen-year-old, rebellious, sexually awakening
daughter who was in the midst of a search for her identity and autonomy! From
there it was but a short step for the group, and then for Diana herself, to
understand that her conflict with her daughter was being played out in the here-
and-now of the group.
There are many occasions when the process is obvious to all the members in the group
but cannot be commented upon simply because the situation is too hot: the members are
too much a part of the interaction to separate themselves from it. In fact, often, even at a
distance, the therapist, too, feels the heat and is wary about naming the beast. Sometimes
an inexperienced therapist may naively determine it best that some group member address
an issue in the group that the leader himself feels too anxious to address. That is usually an
error: the therapist has a greater ability to speak the unspeakable and to find palatable
ways to say unpalatable things. Language is to the therapist what the scalpel is to the
surgeon.
• One neophyte therapist leading an experiential group of pediatric oncology
nurses (a support group intended to help members decrease the stress experienced
in their work) learned through collusive glances between members in the first
meeting that there was considerable unspoken tension between the young,
progressive nurses and the older, conservative nursing supervisors in the group.
The therapist felt that the issue, reaching deep into taboo regions of authority and
tradition, was too sensitive and potentially explosive to touch. His supervisor
assured him that it was too important an issue to leave unexplored and that he
should broach it, since it was highly unlikely that anyone else in the group could
do what he dared not.
In the next meeting, the therapist broached the issue in a manner that is almost
invariably effective in minimizing defensiveness: he described his own dilemma
about the issue. He told the group that he sensed a hierarchical struggle between
the junior nurses and the powerful senior nurses but that he was hesitant to bring
it up lest the younger nurses either deny it or attack the supervisors, who might be
so wounded that they would decide to scuttle the group. His comment was
enormously helpful and plunged the group into an open and constructive
exploration of a vital issue.
Articulating the dilemma in a balanced, nonblaming fashion is often the most effective
way to reduce the tension that obstructs the group’s work. Group leaders need not have a
complete answer to the dilemma—but they do need to be able to identify and speak to it.†
I do not mean that only the leader should make process comments. As I shall discuss
later, other members are entirely capable of performing this function; in fact, there are

times when their process observations will be more readily accepted than those of the
therapists.
A greater ability to recognize process in interactions, perhaps a form of emotional
intelligence, is an important outcome of group therapy that will serve members well in
life.† (Often, students observing a mature group at work are amazed by group members’
high level of psychological-mindedness.) Hence, it is a good thing for members to learn to
identify and comment on process. But it is important that they not assume this function for
defensive reasons—for example, to avoid the client role or in any other way to remove
themselves from the group work.
Thus far in this discussion I have, for pedagogical reasons, overstated two fundamental
points that I must now qualify. Those points are: (1) the here-and-now approach is an
ahistorical one, and (2) there is a sharp distinction between here-and-now experience and
here-and-now process illumination.
Strictly speaking, an ahistorical approach is an impossibility: every process comment
refers to an act that already belongs to the past. (Sartre once said, “Introspection is
retrospection.”) Not only does process commentary involve behavior that has just
transpired, but it frequently refers to cycles of behavior or repetitive acts that have
occurred in the group over weeks or months. Thus, the past events of the therapy group
are a part of the here-and-now and an integral part of the data on which process
commentary is based.
Often it is helpful to ask clients to review their past experiences in the group. If a
member feels that she is exploited every time she trusts someone or reveals herself, I often
inquire about her history of experiencing that feeling in this group. Other clients,
depending upon the relevant issues, may be encouraged to discuss such experiences as the
times they have felt most close to others, most angry, most accepted, or most ignored.
My qualification of the ahistorical approach goes even further. As I will discuss later in
a separate section, no group can maintain a total here-and-now approach. There will be
frequent excursions into the “then-and-there”—that is, into personal history and into
current life situations. In fact, such excursions are so inevitable that one becomes curious
when they do not occur. It is not that the group doesn’t deal with the past; it is what is
done with the past: the crucial task is not to uncover, to piece together, to fully understand
the past, but to use the past for the help it offers in understanding (and changing) the
individual’s mode of relating to the others in the present.
The distinction between here-and-now experience and here-and-now process
commentary is not sharp: there is much overlap. For example, low-inference commentary
(feedback) is both experience and commentary. When one member remarks that another
refuses to look at her or that she is furious at another for continually deprecating her, she is
at the same time commenting on process and involving herself in the affective here-and-
now experience of the group. Process commentary, like nascent oxygen, exists for only a
short time; it rapidly becomes incorporated into the experiential flow of the group and
becomes part of the data from which future process comments will flow.

For example, in a experiential group of mental health trainees (a group experience that
was part of their group therapy training curriculum—see chapter 17), one member, John,
began the session with an account of some extreme feelings of depression and
depersonalization. Instead of exploring the member’s dysphoria, the group immediately
began offering him practical advice about his life situation. The leader commented on the
process—on the fact that the group veered away from inquiring more about John’s
experience. The leader’s intervention seemed useful: the group members became more
emotionally engaged, and several discussed their admiration of John’s risk-taking and
their own fear of self-revelation.
Soon afterward, however, a couple of counterdependent members objected to the
leader’s intervention. They felt that the leader was dissatisfied with their performance in
the group, that he was criticizing them, and, in his usual subtle manner, was manipulating
the group to fit in with his preconceived notions of the proper conduct of a meeting. Other
members took issue with the tendency of some members to challenge every move of the
therapist. Thus, the leader’s process comments became part of the experiential ebb and
flow of the group. Even the members’ criticism of the leader (which was at first process
commentary) soon also became part of the group experience and, itself, subject to process
commentary.
Summary
The effective use of the here-and-now focus requires two steps: experience in here-and-
now and process illumination. The combination of these two steps imbues an experiential
group with compelling potency.
The therapist has different tasks in each step. First the group must be plunged into the
here-and-now experience; second, the group must be helped to understand the process of
the here-and-now experience: that is, what the interaction conveys about the nature of the
members’ relationships with one another.
The first step, here-and-now activation, becomes part of the group norm structure;
ultimately the group members will assist the therapist in this task. The second step,
process illumination, is more difficult. There are powerful injunctions against process
commentary in everyday social intercourse that the therapist must overcome. The task of
process commentary, to a large extent (but not exclusively), remains the responsibility of
the therapist and consists, as I will discuss shortly, of a wide and complex range of
behavior—from labeling single behavioral acts, to juxtaposing several acts, to combining
acts over time into a pattern of behavior, to pointing out the undesirable consequences of
a client’s behavioral patterns, to identifying here-and-now behaviors that are analogues to
the members’ behavior in the world at large, to more complex inferential explanations or
interpretations about the meaning and motivation of such behavior.

TECHNIQUES OF HERE-AND-NOW ACTIVATION
In this section I wish to describe (but not prescribe) some techniques: each therapist must
develop techniques consonant with his or her personal style. Indeed, therapists have a
more important task than mastering a technique: they must fully comprehend the strategy
and theoretical foundations upon which all effective technique must rest.
First step: I suggest that you think here-and-now. When you grow accustomed to
thinking of the here-and-now, you automatically steer the group into the here-and-now.
Sometimes I feel like a shepherd herding a flock into an ever-tightening circle. I head off
errant strays—forays into personal historical material, discussions of current life
situations, intellectualisms—and guide them back into the circle. Whenever an issue is
raised in the group, I think, “How can I relate this to the group’s primary task? How can I
make it come to life in the here-and-now?” I am relentless in this effort, and I begin it in
the very first meeting of the group.
Consider a typical first meeting of a group. After a short, awkward pause, the members
generally introduce themselves and proceed, often with help from the therapist, to tell
something about their life problems, why they have sought therapy, and, perhaps, the type
of distress they suffer. I generally intervene at some convenient point well into the meeting
and remark something like, “We’ve done a great deal here today so far. Each of you has
shared a great deal about yourself, your pain, your reasons for seeking help. But I have a
hunch that something else is also going on, and that is that you’re sizing one another up,
each arriving at some impressions of the others, each wondering how you’ll fit in with the
others. I wonder now if we could spend some time discussing what each of us has come
up with thus far.” Now this is no subtle, artful, shaping statement: it is a heavy-handed,
explicit directive. Yet I find that most groups respond favorably to such clear guidelines
and readily appreciate the therapeutic facilitation.
The therapist moves the focus from outside to inside, from the abstract to the specific,
from the generic to the personal, from the personal into the interpersonal. If a member
describes a hostile confrontation with a spouse or roommate, the therapist may, at some
point, inquire, “If you were to be angry like that with anyone in the group, with whom
would it be?” or, “With whom in the group can you foresee getting into the same type of
struggle?” If a member comments that one of his problems is that he lies, or that he
stereotypes people, or that he manipulates groups, the therapist may inquire, “What is the
main lie you’ve told in the group thus far?” or, “Can you describe the way you’ve
stereotyped some of us?” or, “To what extent have you manipulated the group thus far?”
If a client complains of mysterious flashes of anger or suicidal compulsions, the
therapist may urge the client to signal to the group the very moment such feelings occur
during the session, so that the group can track down and relate these experiences to events
in the session.
If a member describes her problem as being too passive, too easily influenced by others,
the therapist may move her directly into the issue by asking, “Who in the group could

influence you the most? The least?”
If a member comments that the group is too polite and too tactful, the therapist may ask,
“Who are the leaders of the peace-and-tact movement in the group?” If a member is
terrified of revealing himself and fears humiliation, the therapist may bring it into the
here-and-now by asking him to identify those in the group he imagines might be most
likely to ridicule him. Don’t be satisfied by answers of “the whole group.” Press the
member further. Often it helps to rephrase the question in a gentler manner, for example,
“Who in the group is least likely to ridicule you?”
In each of these instances, the therapist can deepen interaction by encouraging further
responses from the others. For example, “How do you feel about his fear or prediction that
you would ridicule him? Can you imagine doing that? Do you, at times, feel judgmental in
the group? Even simple techniques of asking group members to speak directly to one
another, to use second-person (“you”) rather than third-person pronouns, and to look at
one another are very useful.
Easier said than done! Such suggestions are not always heeded. To some group
members, they are threatening indeed, and the therapist must here, as always, employ
good timing and attempt to experience what the client is experiencing. Search for methods
that lessen the threat. Begin by focusing on positive interaction: “Toward whom in the
group do you feel most warm?” “Who in the group is most like you?” or, “Obviously,
there are some strong vibes, both positive and negative, going on between you and John. I
wonder what you most envy or admire about him? And what parts of him do you find
most difficult to accept?”
• A group meeting of elderly clients attending a psychiatric day hospital for
treatment of depression groaned with feelings of disconnection and despair. The
initial focus of the meeting was Sara—an eighty-two-year-old Holocaust survivor.
Sara lamented the persistent prejudice, hatred, and racism so prominent in the
news headlines. Feeling scared and helpless, she discussed her wartime memories
of being dehumanized by those who hated her without knowing anything about her
as a real person. Group members, including other Holocaust survivors, also
shared their tortured memories.
The group leader attempted to break into the group’s intense preoccupation with
the past by shifting into the here-and-now. What did Sara experience talking to the
group today? Did she feel that the group members were engaging her as a real
person? Why had she chosen to be different today—to speak out rather than
silence herself as she has done so often before? Could she take credit for that?
How did others feel about Sara speaking out in this meeting?
Gradually the meeting’s focus shifted from the recounting of despairing
memories to lively interaction, support for Sara, and strong feelings of member
connectivity.
Sometimes, it is easier for group members to work in tandem or in small subgroups. For
example, if they learn that there is another member with similar fears or concerns, then a

subgroup of two (or more) members can, with less threat, discuss their here-and-now
concerns.7 This may occur spontaneously or by the therapist directly creating a bridge
between specific members—for example, by pointing out that the concerns just disclosed
by one member have also been expressed by another.†
Using the conditional verb form provides safety and distance and often is miraculously
facilitative. I use it frequently when I encounter initial resistance. If, for example, a client
says, “I don’t have any response or feelings at all about Mary today. I’m just feeling too
numb and withdrawn,” I often say something like, “If you were not numb or withdrawn
today, what might you feel about Mary?” The client generally answers readily; the once-
removed position affords a refuge and encourages the client to answer honestly and
directly. Similarly, the therapist might inquire, “If you were to be angry at someone in the
group, whom would it be?” or, “If you were to go on a date with Albert (another group
member), what kind of experience might it be?”
The therapist must teach members the art of requesting and offering feedback by
explicit instruction, by modeling, or by reinforcing effective feedback.8 One important
principle to teach clients is the avoidance of global questions and observations. Questions
such as “Am I boring?” or “Do you like me?” are not usually productive. A client learns a
great deal more by asking, “What do I do that causes you to tune out?” “When are you
most and least attentive to me?” or, “What parts of me or aspects of my behavior do you
like least and most?” In the same vein, feedback such as “You’re OK” or “You’re a nice
guy” is far less useful than “I feel closer to you when you’re willing to be honest with
your feelings, like in last week’s meeting when you said you were attracted to Mary but
feared she would scorn you. I feel most distant from you when you’re impersonal and start
analyzing the meaning of every word said to you, like you did early in the meeting today.”
(These comments, like most of the therapist comments in this text, have equal applicability
in individual therapy.)
Resistance occurs in many forms. Often it appears in the cunning guise of total equality.
Clients, especially in early meetings, often respond to the therapist’s here-and-now urgings
by claiming that they feel exactly the same toward all the group members: that is, they say
that they feel equally warm toward all the members, or no anger toward any, or equally
influenced or threatened by all. Do not be misled. Such claims are never true. Guided by
your sense of timing, push the inquiry farther and help members differentiate one another.
Eventually they will disclose that they do have slight differences of feeling toward some
of the members. These slight differences are important and are often the vestibule to full
interactional participation. I explore the slight differences (no one ever said they had to be
enormous); sometimes I suggest that the client hold up a magnifying glass to these
differences and describe what he or she then sees and feels. Often resistance is deeply
ingrained and the client is heavily invested in maintaining a position that is known and
familiar even though it is undermining or personally destructive.
Resistance is not usually conscious obstinacy but more often stems from sources
outside of awareness. Sometimes the here-and-now task is so unfamiliar and
uncomfortable to the client that it is not unlike learning a new language; one has to attend

with maximal concentration in order not to slip back into one’s habitual remoteness.
Considerable ingenuity on the part of the therapist may be needed, as the following case
study shows.
• Claudia resisted participation on a here-and-now level for many sessions.
Typically she brought to the group some pressing current life problem, often one of
such crisis proportions that the group members felt trapped. First, they felt
compelled to deal immediately with the precise problem Claudia presented;
second, they had to tread cautiously because she explicitly informed them that she
needed all her resources to cope with the crisis and could not afford to be shaken
up by interpersonal confrontation. “Don’t push me right now,” she might say, “I’m
just barely hanging on.” Efforts to alter this pattern were unsuccessful, and the
group members felt discouraged in dealing with Claudia. They cringed when she
brought in problems to the meeting.
One day she opened the group with a typical gambit. After weeks of searching
she had obtained a new job but was convinced that she was going to fail and be
dismissed. The group dutifully but warily investigated the situation. The
investigation met with many of the familiar, treacherous obstacles that generally
block the path of work on outside problems. There seemed to be no objective
evidence that Claudia was failing at work. She seemed, if anything, to be trying too
hard, working eighty hours a week. The evidence, Claudia insisted, simply could
not be appreciated by anyone not there at work with her: the glances of her
supervisor, the subtle innuendos, the air of dissatisfaction toward her, the general
ambiance in the office, the failure to live up to her (selfimposed and unrealistic)
sales goals. It was difficult to evaluate what she said because she was not a highly
unreliable observer and typically downgraded herself and minimized her
accomplishments.
The therapist moved the entire transaction into the here-and-now by asking,
“Claudia, it’s hard for us to determine whether you are, in fact, failing at your job.
But let me ask you another question: What grade do you think you deserve for your
work in the group, and what do each of the others get?”
Claudia, not unexpectedly, awarded herself a “D–” and staked her claim for at
least eight more years in the group. She awarded all the other members
substantially higher grades. The therapist replied by awarding Claudia a “B” for
her work in the group and then went on to point out the reasons: her commitment
to the group, perfect attendance, willingness to help others, great efforts to work
despite anxiety and often disabling depression.
Claudia laughed it off, trying to brush off this exchange as a gag or a
therapeutic ploy. But the therapist held firm and insisted that he was entirely
serious. Claudia then insisted that the therapist was wrong, and pointed out her
many failings in the group (one of which was the avoidance of the here-and-now).
However, Claudia’s disagreement with the therapist created dissonance for her,
since it was incompatible with her long-held, frequently voiced, total confidence in

the therapist. (Claudia had often invalidated the feedback of other members in the
group by claiming that she trusted no one’s judgment except the therapist’s.)
The intervention was enormously useful and transferred the process of Claudia’s
evaluation of herself from a secret chamber lined with the distorting mirrors of her self-
perception to the open, vital arena of the group. No longer was it necessary for the
members to accept Claudia’s perception of her boss’s glares and subtle innuendoes. The
boss (the therapist) was there in the group. The whole transaction was visible to the group.
Finding the here-and-now experiential analogue of the untrustworthy “then-and-there”
reported difficulties unlocked the therapeutic process for Claudia.
I never cease to be awed by the rich, subterranean lode of data that exists in every group
and in every meeting. Beneath each sentiment expressed there are layers of invisible,
unvoiced ones. But how to tap these riches? Sometimes after a long silence in a meeting, I
express this very thought: “There is so much information that could be valuable to us all
today if only we could excavate it. I wonder if we could, each of us, tell the group about
some thoughts that occurred to us in this silence, which we thought of saying but didn’t.”
The exercise is more effective, incidentally, if you participate personally, even start it
going. Substantial empirical evidence supports the principle that therapists who employ
judicious and disciplined self-disclosure, centered in the here-and-now of the therapeutic
relationship, increase their therapeutic effectiveness and facilitate clients’ exploration and
openness.9 For example, you might say, “I’ve been feeling on edge in this silence, wanting
to break it, not wanting to waste time, but on the other hand feeling irritated that it always
has to be me doing this work for the group.” Or, “I’ve been feeling uneasy about the
struggle going on in the group between you and me, Mike. I’m uncomfortable with this
much tension and anger, but I don’t know yet how to help understand and resolve it.”
When I feel there has been a particularly great deal unsaid in a meeting, I have often
found the following technique useful: “It’s now six o’clock and we still have half an hour
left, but I wonder if you each would imagine that the meeting has ended and that you’re on
your way home. What disappointments would you have about the meeting today?”
Many of the inferences the therapist makes may be off-target. But objective accuracy is
not the issue: as long as you persistently direct the group from the nonrelevant, from the
then-and-there, to the here-and-now, you are operationally correct. For example, if a
group spends time in an unproductive meeting discussing dull, boring parties, and the
therapist wonders aloud if the members are indirectly referring to the present group
session, there is no way of determining with any certainty whether that is an accurate
statement. Correctness in this instance must be defined relativistically and pragmatically.
By shifting the group’s attention from then-and-there to here-and-now material, the
therapist performs a service to the group—a service that, consistently reinforced, will
ultimately result in a cohesive, interactional atmosphere maximally conducive to therapy.
Following this model, the effectiveness of an intervention should be gauged by its success
in focusing the group on itself.
According to this principle, the therapist might ask a group that dwells at length on the
subject of poor health or on a member’s sense of guilt over remaining in bed during times

of sickness, “Is the group really wondering about my [the therapist’s] recent illness?” Or a
group suddenly preoccupied with death and the losses each member has incurred might be
asked whether they are also concerned with the group’s impending fourweek summer
vacation. In these instances the leader attempts to make connections between the overt
content and underlying unexpressed covert group-related issues.
Obviously, these interventions would be pointless if the group had already thoroughly
worked through all the implications of the therapist’s recent absence or the impending
summer break. The technical procedure is not unlike the sifting process in any traditional
psychotherapy. Presented with voluminous data in considerable disarray, the therapist
selects, reinforces, and interprets those aspects he deems most helpful to the client at that
particular time. Not all dreams and not all parts of a dream are attended to by the therapist;
however, a dream theme that elucidates a particular issue on which the client is currently
working is vigorously pursued.
Implicit here is the assumption that the therapist knows the most propitious direction for
the group at a specific moment. Again, this is not a precise matter. What is most important
is that the therapist has formulated broad principles of ultimately helpful directions for the
group and its members—this is precisely where a grasp of the therapeutic factors is
essential.
Often, when activating the group, the therapist performs two simultaneous acts: steering
the group into the here-and-now and, at the same time, interrupting the content flow in the
group. Not infrequently, some members will resent the interruption, and the therapist must
attend to these feelings, for they, too, are part of the here-and-now. Often it is difficult for
the therapist to intervene. Early in our socialization process we learn not to interrupt, not
to change the subject abruptly. Furthermore, there are often times in the group when
everyone seems keenly interested in the topic under discussion. Even though the therapist
is certain that the group is not working, it is not easy to buck the group current. As noted
in chapter 3, social-psychological small-group research demonstrates the compelling
power of group pressure. To take a stand opposite to the perceived consensus of the group
requires considerable courage and conviction.
My experience is that the therapist faced with this as well as many other types of
dilemmas can increase the clients’ receptivity by expressing both sets of feelings to the
group. For example, “Lily, I feel very uncomfortable as you talk. I’m having a couple of
strong feelings. One is that you’re into something that is very important and painful for
you, and the other is that Jason [a new member] has been trying hard to get into the group
for the last few meetings and the group seems unwelcoming. This didn’t happen when
other new members entered the group. Why do you think it’s happening now?” Or,
“Lenore, I’ve had two reactions as you started talking. The first is that I’m delighted you
feel comfortable enough now in the group to participate, but the other is that it’s going to
be hard for the group to respond to what you’re saying because it’s very abstract and far
removed from you personally. I’d be much more interested in how you’ve been feeling
about the group the last couple of meetings. Are there some incidents or interactions
you’ve been especially tuned in to? What reactions have you had to other members here?”

There are, of course, many more such activating procedures. (In chapter 14, I describe
some basic modifications in the group structure and procedure that facilitate here-and-now
interaction in short-term specialty groups.) But my goal here is not to offer a compendium
of techniques. Rather, I describe techniques only to illuminate the underlying principle of
here-and-now activation. These group techniques, or gimmicks, are servants, not masters.
To use them injudiciously, to fill voids, to jazz up the group, to acquiesce to the members’
demands that the leader lead, is seductive but not constructive for the group.10
Overall, group leader activity correlates with outcome in a curvilinear fashion (too
much or too little activity leads to unsuccessful outcomes). Too little leader activity results
in a floundering group. Too much activation by a leader results in a dependent group that
persists in looking to the leader to supply too much.
Remember that sheer acceleration of interaction is not the purpose of these techniques.
The therapist who moves too quickly—using gimmicks to make interactions, emotional
expression, and self-disclosure too easy—misses the whole point. Resistance, fear,
guardedness, distrust—in short, everything that impedes the development of satisfying
interpersonal relations—must be permitted expression. The goal is to create not a slick-
functioning, streamlined social organization but one that functions well enough and
engenders sufficient trust for the unfolding of each member’s social microcosm. Working
through the resistances to change is the key to the production of change.
Thus, the therapist wants to go not around obstacles but through them. Ormont puts it
nicely when he points out that though we urge clients to engage deeply in the here-and-
now, we expect them to fail, to default on their contract. In fact, we want them to default
because we hope, through the nature of their failure, to identify and ultimately dispel each
member’s particular resistances to intimacy—including each member’s resistance style
(for example, detachment, fighting, diverting, self-absorption, distrust) and each member’s
underlying fears of intimacy (for example, impulsivity, abandonment, merger,
vulnerability).11
TECHNIQUES OF PROCESS ILLUMINATION
As soon as clients have been successfully steered into a here-and-now interactional
pattern, the group therapist must attend to turning this interaction to therapeutic advantage.
This task is complex and consists of several stages:
• Clients must first recognize what they are doing with other people (ranging from
simple acts to complex patterns unfolding over a long time).
• They must then appreciate the impact of this behavior on others and how it
influences others’ opinion of them and consequently its impact on their own self-
regard.
• They must decide whether they are satisfied with their habitual interpersonal style.

• They must exercise the will to change.
• They must transform intent into decision and decision into action.
• Lastly, they must solidify the change and transfer it from the group setting into their
larger life.
Each of these stages may be facilitated by some specific cognitive input by the
therapist, and I will describe each step in turn. First, however, I must discuss several prior
considerations: How does the therapist recognize process? How can the therapist help the
members assume a process orientation? How can therapists increase the client receptivity
of their process commentary?
Recognition of Process
Before therapists can help clients understand process, they must themselves learn to
recognize it: in other words, they must be able to reflect in the midst of the group
interaction and wonder, “Why is this unfolding in this group in this particular way and at
this particular time?Ӡ The experienced therapist does this naturally and effortlessly,
observing the group proceedings from several different perspectives, including the specific
individual interactions and the developmental issues in the group (see chapter 11). This
difference in perspective is the major difference in role between the client and the
therapist. Consider some clinical illustrations:
• At one meeting, Alana discloses much deep personal material. The group is
moved by her account and devotes much time to listening, to helping her elaborate
more fully, and to offering support. The therapist shares in these activities but
entertains many other thoughts as well. For example, the therapist may wonder
why, of all the members, it is invariably Alana who reveals first and most. Why
does Alana so often put herself in the role of the group member whom all the
members must nurse? Why must she always display herself as vulnerable? And
why today? And that last meeting! So much conflict! After such a meeting, one
might have expected Alana to be angry. Instead, she shows her throat. Is she
avoiding giving expression to her rage?
• At the end of a session in another group, Jay, a young, rather fragile young man
who had been inactive in the group, revealed that he was gay—his first step out of
the closet. At the next meeting the group urged him to continue. He attempted to do
so but, overcome with emotion, blocked and hesitated. Just then, with indecent
alacrity, Vicky filled the gap, saying, “Well, if no one else is going to talk, I have a
problem.”
Vicky, an aggressive forty-year-old cabdriver, who sought therapy because of
social loneliness and bitterness, proceeded to discuss in endless detail a complex
situation involving an unwelcome visiting aunt. For the experienced, process-
oriented therapist, the phrase “I have a problem” is a double entendre. Far more
trenchantly than her words, Vicky’s behavior declares, “I have a problem,” and

her problem is manifest in her insensitivity to Jay, who, after months of silence,
had finally mustered the courage to speak.
It is not easy to tell the beginning therapist how to recognize process; the acquisition of
this perspective is one of the major tasks in your education. And it is an interminable task:
throughout your career, you learn to penetrate ever more deeply into the substratum of
group discourse. This deeper vision increases the keenness of a therapist’s interest in the
meeting. Generally, beginning students who observe meetings find them far less
meaningful, complex, and interesting than do experienced therapists.
Certain guidelines, though, may facilitate the neophyte therapist’s recognition of
process. Note the simple nonverbal sense data available.† Who chooses to sit where?
Which members sit together? Who chooses to sit close to the therapist? Far away? Who
sits near the door? Who comes to the meeting on time? Who is habitually late? Who looks
at whom when speaking? Do some members, while speaking to another member, look at
the therapist? If so, then they are relating not to one another but instead to the therapist
through their speech to the others. Who looks at his watch? Who slouches in her seat?
Who yawns? Do the members pull their chairs away from the center at the same time as
they are verbally professing great interest in the group? How quickly do the group
members enter the room? How do they leave it? Are coats kept on? When in a single
meeting or in the sequence of meetings are they removed? A change in dress or grooming
not uncommonly indicates change in a client or in the atmosphere of the entire group. An
unctuous, dependent man may express his first flicker of rebellion against the leader by
wearing jeans and sneakers to a group session rather than his usual formal garb.
A large variety of postural shifts may betoken discomfort; foot flexion, for example, is a
particularly common sign of anxiety. Indeed, it is common knowledge that nonverbal
behavior frequently expresses feelings of which a person is yet unaware. The therapist,
through observing and teaching the group to observe nonverbal behavior, may hasten the
process of self-exploration.
Assume that every communication has meaning and salience within the individual’s
interpersonal schema until proven otherwise. Make use of your own reactions to each
client as a source of process data.12 Keep attending to the reactions that group members
elicit in one another. Which seem consensual reactions shared by most, and which are
unique or idiosyncratic reactions?13
Sometimes the process is clarified by attending not only to what is said but also to what
is omitted: the female member who offers suggestions, advice, or feedback to the male
members but never to the other women in the group; the group that never confronts or
questions the therapist; the topics (for example, the taboo trio: sex, money, death) that are
never broached; the individual who is never attacked; the one who is never supported; the
one who never supports or inquires—all these omissions are part of the transactional
process of the group.
• In one group, for example, Sonia stated that she felt others disliked her. When
asked who, she selected Eric, a detached, aloof man who habitually related only to

those who could be of use to him. Eric bristled, “Why me? Tell me one thing I’ve
said to you that makes you pick me.” Sonia stated, “That’s exactly the point.
You’ve never said anything to me. Not a question, not a greeting. Nothing. I just
don’t exist for you. You have no use for me.” Eric, later, at a debriefing session
after completing therapy, cited this incident as a particularly powerful and
illuminating instruction.
Physiologists commonly study the function of a hormone by removing the endocrine
gland that manufactures it and observing the changes in the hormone-deficient organism.
Similarly, in group therapy, we may learn a great deal about the role of a particular
member by observing the here-and-now process of the group when that member is absent.
For example, if the absent member is aggressive and competitive, the group may feel
liberated. Other members, who had felt threatened or restricted in the missing member’s
presence, may suddenly blossom into activity. If, on the other hand, the group has
depended on the missing member to carry the burden of self-disclosure or to coax other
members into speaking, then it will feel helpless and threatened when that member is
absent. Often this absence elucidates interpersonal feelings that previously were entirely
out of the group members’ awareness. The therapist may then encourage the group to
discuss these feelings toward the absent member both at that time and later in his or her
presence. A common myth that may need to be dispelled is that talking about a group
member when he is not present at a meeting is politically or socially incorrect. It is not
“talking behind someone’s back” and it should not lead to scapegoating, provided that the
group adopts the practice of sharing the discussion with that member at the following
meeting.
Similarly, a rich supply of data about feelings toward the therapist often emerges in a
meeting in which the therapist or a co-therapist is absent. One leader led an experiential
training group of mental health professionals composed of one woman and twelve men.
The woman, though she habitually took the chair closest to the door, felt reasonably
comfortable in the group until a leaderless meeting was scheduled when the therapist was
out of town. At that meeting the group discussed sexual feelings and experiences far more
blatantly than ever before, and the woman had terrifying fantasies of the group locking the
door and raping her. She realized how the therapist’s presence had offered her safety
against fears of unrestrained sexual behavior by the other members and against the
emergence of her own sexual fantasies. (She realized, too, the meaning of her occupying
the seat nearest the door!)
Search in every possible way to understand the relationship messages in any
communication. Look for incongruence between verbal and nonverbal behavior. Be
especially curious when there is something arrhythmic about a transaction: when, for
example, the intensity of a response seems disproportionate to the stimulus statement, or
when a response seems to be off target or to make no sense. At these times look for
several possibilities: for example, parataxic distortion (the responder is experiencing the
sender unrealistically), or metacommunication (the responder is responding, accurately,
not to the manifest content but to another level of communication), or displacement (the
responder is reacting not to the current transaction but to feelings stemming from previous

transactions). A disproportionately strong emotional reaction—what one group member
called “A Big Feeling”—may be the tip of an iceberg of deeper, historical concerns that
get reactivated in the present.
Common Group Tensions
Remember that, to some degree, certain tensions are always present in every therapy
group. Consider, for example, tensions such as the struggle for dominance, the antagonism
between mutually supportive feelings and sibling rivalrous ones, between greed and
selfless efforts to help the other, between the desire to immerse oneself in the comforting
waters of the group and the fear of losing one’s precious individuality, between the wish to
get better and the wish to stay in the group, between the wish that others improve and the
fear of being left behind. Sometimes these tensions are quiescent for months until some
event wakens them and they erupt into plain view.
Do not forget these tensions. They are omnipresent, always fueling the hidden motors of
group interaction. The knowledge of these tensions often informs the therapist’s
recognition of process. Consider, for example, one of the most powerful covert sources of
group tension: the struggle for dominance. Earlier in this chapter, I described an
intervention where the therapist, in an effort to steer a client into the here-and-now, gave
her a grade for her work in the group. The intervention was effective for that particular
person. Yet that was not the end of the story: there were later repercussions on the rest of
the group. In the next meeting, two group members asked the therapist to clarify some
remark he had made to them at a previous meeting. The remarks had been so supportive in
nature and so straightforwardly phrased that the therapist was puzzled at the request for
clarification. Deeper investigation revealed that the two members and later others, too,
were requesting grades from the therapist.
• In another experiential group of mental health professionals at several levels of
training, the leader was much impressed by the group skills of Stewart, one of the
youngest, most inexperienced members. The leader expressed his fantasy that
Stewart was a plant, that he could not possibly be just beginning his training, since
he conducted himself like a veteran with ten years’ group experience. The comment
evoked a flood of tensions. It was not easily forgotten by the group and, for
sessions to come, was periodically revived and angrily discussed. With his
comment, the therapist placed the kiss of death on Stewart’s brow, since thereafter
the group systematically challenged and deskilled him. It is to be expected that the
therapist’s positive evaluation of one member will evoke feelings of sibling rivalry
among the others.
The struggle for dominance, as I will discuss in chapter 11, fluctuates in intensity
throughout the group. It is much in evidence at the beginning of the group as members
jockey for position in the pecking order. Once the hierarchy is established, the issue may
become quiescent, with periodic flare-ups, for example, when some member, as part of his
or her therapeutic work, begins to grow in assertiveness and to challenge the established

order.
When new members enter the group, especially aggressive members who do not know
their place, who do not respectfully search out and honor the rules of the group, you may
be certain that the struggle for dominance will rise to the surface.
• In one group a veteran member, Betty, was much threatened by the entrance of a
new, aggressive woman, Rena. A few meetings later, when Betty discussed some
important material concerning her inability to assert herself, Rena attempted to
help by commenting that she, herself, used to be like that, and then she presented
various methods she had used to overcome it. Rena reassured Betty that if she
continued to talk about it openly in the group she, too, would gain considerable
confidence. Betty’s response was silent fury of such magnitude that several
meetings passed before she could discuss and work through her feelings. To the
uninformed observer, Betty’s response would appear puzzling; but in the light of
Betty’s seniority in the group and Rena’s vigorous challenge to that seniority, her
response was entirely predictable. She responded not to Rena’s manifest offer of
help but instead to Rena’s implicit communication: “I’m more advanced than you,
more mature, more knowledgeable about the process of psychotherapy, and more
powerful in this group despite your longer presence here.”
• In another group, Bea, an assertive, articulate woman, had for months been the
most active and influential member. A new member, Bob, a psychiatric social
worker (who did not reveal that fact to the group), was introduced. He was
exceedingly assertive and articulate and in his first meeting, described his life
situation with such candor and clarity that the other members were impressed and
touched. Bea’s response, however, was: “Where did you get your group therapy
training?” (Not “Did you ever have therapy training?” or, “You sound like you’ve
had some experience in examining yourself.”) The wording of Bea’s comment
clearly revealed the struggle for dominance, for she was implicitly saying: “I’ve
found you out. Don’t think you can fool me with that jargon. You’ve got a long way
to go to catch up with me!”
Primary Task and Secondary Gratification
The concepts of primary task and secondary gratification, and the dynamic tension
between the two, provide the therapist with a useful guide to the recognition of process
(and, as I will discuss later, a guide to the factors underlying a client’s resistance to
process commentary).
First some definitions. The primary task of the client is, quite simply, to achieve his or
her original goals: relief of suffering, better relationships with others, or living more
productively and fully. Yet, as we examine it more closely, the task often becomes much
more complicated. Generally one’s view of the primary task changes considerably as one
progresses in therapy. Sometimes the client and the therapist have widely different views
of the primary task. I have, for example, known clients who stated that their goal is relief

from pain (for example, from anxiety, depression, or insomnia) but who have a deeper and
more problematic goal. One woman wished that through therapy she would become so
well that she would be even more superior to her adversaries by “out mental-healthing”
them; another client wished to learn how to manipulate others even more effectively;
another wished to become a more effective seducer. These goals may be unconscious or,
even if conscious, well hidden from others; they are not part of the initial contract the
individual makes with the therapist, and yet they exert a pervasive influence in the
therapeutic work. In fact, much therapy may have to occur before some clients can
formulate an appropriate primary task.14 m
Even though their goals may evolve through the course of therapy, clients initially have
some clear conception of a primary task—generally, relief of some type of discomfort. By
methods discussed in chapter 10, therapists, in pregroup preparations of clients and in the
first group meetings, make clients aware of what they must do in the group to accomplish
their primary tasks. And yet once the group begins, very peculiar things begin to happen:
clients conscious wish for change there is a deeper commitment to avoid change—a
clinging to old familiar modes of behavior. It is often through the recognition of this
clinging (that is, resistance) that the first real opportunity for repair emerges.†
Some clinical vignettes illustrate this paradox:
• Cal, a young man, was interested in seducing the women of the group and shaped
his behavior in an effort to appear suave and charming. He concealed his feelings
of awkwardness, his desperate wish to be cool, his fear of women, and his envy of
some of the men in the group. He could never discuss his compulsive masturbation
and occasional voyeurism. When another male member discussed his disdain for
the women in the group, Cal (purring with pleasure at the withdrawal of
competition) praised him for his honesty. When another member discussed, with
much anxiety, his homosexual fantasies, Cal deliberately withheld the solace he
might have offered by sharing his own, similar fantasies. He never dared to discuss
the issues for which he entered therapy; nothing took precedence over being cool.
Another member devoted all her energies to achieving an image of mental
agility and profundity. She, often in subtle ways, continually took issue with me.
She scorned any help I offered her, and took great offense at my attempts to
interpret her behavior. Finally, I reflected that working with her made me feel I had
nothing of value to offer. That was her finest hour! She flashed a sunny smile as
she said, “Perhaps you ought to join a therapy group to work on your problem.”
Another member enjoyed an enviable position in the group because of his
girlfriend, a beautiful actress, whose picture he delighted in passing around in the
group. She was his showpiece, living proof of his natural superiority. When one
day she suddenly and peremptorily left him, he was too mortified to face the group
and dropped out of therapy.
What do these examples have in common? In each, the client gave priority not to the
declared primary task but to some secondary gratification arising in the group: a
relationship with another member, an image a client wished to project, or a group role in

which a client was the most sexually desirable, the most influential, the most wise, the
most superior. In each instance, the client’s pathology obstructed his or her pursuit of the
primary goal. Clients diverted their energies from the real work of therapy to the pursuit of
some gratification in the group. If this here-and-now behavior were available for study—if
the members could, as it were, be pulled out of the group matrix to observe their actions in
a more dispassionate manner—then the entire sequence would become part of good
therapeutic work. But that did not happen! In all these instances, the gratification took
precedence over the work to be done. Group members concealed information,
misrepresented themselves, rejected the therapist’s help, and refused to give help to one
another.
This is a familiar phenomenon in individual therapy. Long ago, Freud spoke of the
patient whose desire to remain in therapy outweighed the desire to be cured. The
individual therapist satisfies a client’s wish to be succored, to be heard, to be cradled. Yet
there is a vast, quantitative difference in this respect between individual and group
therapy. The individual therapy format is relatively insular; the group situation offers a far
greater range of secondary gratifications, of satisfying many social needs in an
individual’s life. Moreover, the gratification offered is often compelling; our social needs
to be dominant, to be admired, to be loved, to be revered are powerful indeed. For some,
the psychotherapy group provides satisfying relationships rather than being a bridge to
forming better relationships in their world at large. This presents a clinical challenge with
certain populations, such as the elderly, who have reduced opportunities for human
connection outside of the therapy group. In such instances, offering ongoing, less frequent
booster sessions, perhaps monthly, after a shorter intensive phase may be the best way to
respond to this reluctance to end therapy.15
Is the tension that exists between primary task and secondary gratification nothing more
than a slightly different way of referring to the familiar concept of resistance and acting
out? In the sense that the pursuit of secondary gratification obstructs the therapeutic work,
it may generically be labeled resistance. Yet there is an important shade of difference:
Resistance ordinarily refers to pain avoidance. Obviously, resistance in this sense is much
in evidence in group therapy, on both an individual and a group level. But what I wish to
emphasize is that the therapy group offers an abundance of secondary gratifications.
Often the therapeutic work in a group is derailed not because members are too defensively
anxious to work but because they find themselves unwilling to relinquish gratification.
Often, when the therapist is bewildered by the course of events in the therapy group, the
distinction between primary task and secondary gratification is extremely useful. It is
often clarifying for therapists to ask themselves whether the client is working on his or her
primary task. And when the substitution of secondary gratification for primary task is well
entrenched and resists intervention, therapists have no more powerful technique than
reminding the group members of the primary task—the reasons for which they seek
therapy.
The same principle applies to the entire group. It can be said that the entire group has a
primary task that consists of the development and exploration of all aspects of the

relationship of each member to each of the others, to the therapist, and to the group as an
aggregate. The therapist and, later, the group members can easily enough sense when the
group is working, when it is involved in its primary task, and when it is avoiding that task.
At times the therapist may be unclear about what a group is doing but knows that it is
not focused on either developing or exploring relationships between members. If
therapists have attended to providing the group a clear statement of its primary task, then
they must conclude that the group is actively evading the task—either because of some
dysphoria associated with the task itself or because of some secondary gratification that is
sufficiently satisfying to supplant the therapy work.
The Therapist’s Feelings
All of these guides to the therapist’s recognition and understanding of process have their
usefulness. But there is an even more important clue: the therapist’s own feelings in the
meeting, feelings that he or she has come to trust after living through many previous
similar incidents in group therapy. Experienced therapists learn to trust their feelings; they
are as useful to a therapist as a microscope or DNA mapping to a microbiologist. If
therapists feel impatient, frustrated, bored, confused, discouraged—any of the panoply of
feelings available to a human being—they should consider this valuable data and learn to
put it to work.
Remember, this does not mean that therapists have to understand their feelings and
arrange and deliver a neat interpretive corsage. The simple expression of feelings is often
sufficient to help a client proceed further.
• One therapist experienced a forty-five-year-old woman in an unreal, puzzling
manner because of her rapidly fluctuating method of presenting herself. He finally
commented, “Sharon, I have several feelings about you that I’d like to share. As
you talk, I often experience you as a competent mature woman, but sometimes I see
you as a very young, almost preadolescent child, unaware of your sexuality, trying
to cuddle, trying to be pleasing to everyone. I don’t think I can go any farther with
this now, but I wonder whether this has meaning for you.” The observation struck
deep chords in the client and helped her explore her conflicted sexual identity and
her need to be loved by everyone.
It is often very helpful to the group if you share feelings of being shut out by a member.
Such a comment rarely evokes defensiveness, because it always implies that you wish to
get closer to that person. It models important group therapy norms: risk taking,
collaboration, and taking relationships seriously.
To express feelings in the therapeutic process, the therapist must have a reasonable
degree of confidence in their appropriateness. The more you respond unrealistically to the
client (on the basis of countertransference or possibly because of pressing personal
emotional problems), the less helpful—in fact, the more antitherapeutic—will you be in
presenting these feelings as if they were the client’s problem rather than your own. You

need to use the delicate instrument of your own feelings, and to do so frequently and
spontaneously. But it is of the utmost importance that this instrument be as reliable and
accurate as possible.
Countertransference refers broadly to the reactions therapists have to their clients. It is
critically important to distinguish between your objective countertransference, reflecting
on the client’s characteristic interpersonal impact on you and others, and your subjective
countertransference—those idiosyncratic reactions that reflect more specifically on what
you, personally, carry into your relationships or interactions.16 The former is an excellent
source of interpersonal data about the client. The latter, however, says a good deal more
about the therapist. To discriminate between the two requires not only experience and
training but also deep self-knowledge. It is for this reason that I believe every therapist
should obtain personal psychotherapy . (More about this in chapter 17.)
HELPING CLIENTS ASSUME A PROCESS
ORIENTATION
It has long been known that observations, viewpoints, and insights arrived at through one’s
own efforts are valued more highly than those that are thrust upon one by another person.
The mature leader resists the temptation to make brilliant virtuoso interpretations, but
searches instead for methods that will permit clients to achieve self-knowledge through
their own efforts. As Foulkes and Anthony put it, “There are times when the therapist
must sit on his wisdom, must tolerate defective knowledge and wait for the group to arrive
at solutions.”17
The task, then, is to influence members to assume and to value the process perspective.
Many of the norm-setting activities of the leader described in chapter 5 serve this end. For
example, the therapist emphasizes process by periodically tugging the members out of the
here-and-now and inviting them to consider more dispassionately the meaning of recent
transactions. Though techniques vary depending on a therapist’s style, the intention of
these interventions is to switch on a self-reflective beacon. The therapist may, for
example, interrupt the group at an appropriate point to comment, in effect, “We are about
halfway through our time for today, and I wonder how everyone feels about the meeting
thus far?” Again, by no means do you have to understand the process to ask for members’
analyses. You might simply say, “I’m not sure what’s happening in the meeting, but I do
see some unusual things. For example, Bill has been unusually silent, Jack’s moved his
chair back three feet, Mary’s been shooting glances at me for the past several minutes.
What ideas do you all have about what’s going on today?”
A process review of a highly charged meeting is often necessary. It is important for the
therapist to demonstrate that intense emotional expression provides material for significant
learning. Sometimes you can divide such a meeting into two parts: the experiential
segment and the analysis of that experience. At other times you may analyze the process at

the following meeting; you can ask about the feelings that members took home with them
after the previous meeting, or simply solicit further thoughts they have since had about
what occurred there.
Obviously, you teach through modeling your own process orientation. There is nothing
to lose and much to gain by your sharing your perspective on the group whenever
possible. Sometimes you may do this in an effort to clarify the meeting: “Here are some of
the things I’ve seen going on today.” Sometimes you may wish to use a convenient device
such as summarizing the meeting to a late arrival, whether co-therapist or member. One
technique I use that systematically shares my process observations with members is to
write a detailed summary of the meeting afterward, including a full description of my
spoken and unspoken process observations, and mail it to the members before the next
meeting (see chapter 14). With this approach the therapist uses considerable personal and
professional disclosure in a way that facilitates the therapy work, particularly by
increasing the members’ perceptivity to the process of the group.
It is useful to encourage members to describe their views on the process of group
meetings. Many group therapy instructors who teach by leading an experiential group of
their students often begin each meeting with a report, prepared by some designated
student, of the process of the previous meeting. Some therapists learn to call upon certain
members who display unusual intuitive ability to recognize process. For example, Ormont
describes a marginal member in his group who had unusual sensitivity to the body
language of others. The therapist made a point of harnessing that talent for the service of
therapy. A question such as: “Michael, what was Pam saying to Abner with that wave of
her hand?” served a double purpose: illumination of process and helping Michael gain
centrality and respect.18
HELPING CLIENTS ACCEPT PROCESS-
ILLUMINATING COMMENTS
F. Scott Fitzgerald once wrote, “I was impelled to think. God, was it difficult! The moving
about of great secret trunks.” Throughout therapy, we ask our clients to think, to shift
internal arrangements, to examine the consequences of their behavior. It is hard work, and
it is often unpleasant, frightening work. It is not enough simply to provide clients with
information or explanations; you must also facilitate the assimilation of the new
information. There are strategies to help clients in this work.
Be concerned with the framing of interpretive remarks and feedback. No comments, not
even the most brilliant ones, can be of value if their delivery is not accepted, if the client
rejects the package unopened and uninspected. The relationship, the style of delivery, and
the timing are thus as essential as the content of the message.
Clients are always more receptive to observations that are framed in a supportive

fashion. Rarely do individuals reject an observation that they distance or shut out others,
or that they are too unselfish and never ask for anything for themselves, or that they are
stingy with their feelings, or that they conceal much of what they have to offer. All of
these observations contain a supportive message: that the member has much to give and
that the observer wishes to be closer, wishes to help, wishes to know the other more
intimately.
Beware of appellations that are categorizing or limiting: they are counterproductive;
they threaten; they raise defenses. Clients reject global accusations—for example,
dependency, narcissism, exploitation, arrogance—and with good reason, since a person is
always more than any one or any combination of labels. It is far more acceptable (and
true) to speak of traits or parts of an individual—for example, “I often can sense you very
much wanting to be close to others, offering help as you did last week to Debbie. But there
are other times, like today, when I see you as aloof, almost scornful of the others. What do
you know about this part of you?”
Often in the midst of intense group conflict, members hurl important truths at one
another. Under these conditions, one cannot acknowledge the truth: it would be aiding the
aggressor, committing treason against oneself. To make the conflict-spawned truths
available for consumption, the therapist must appreciate and neutralize the defensiveness
of the combatants.
You may, for example, appeal to a higher power (the member’s desire for self-
knowledge) or increase receptivity by limiting the scope of the accusation. For example,
“Farrell, I see you now closed up, threatened, and fending off everything that Jamie is
saying. You’ve been very adroit in pointing out the weaknesses of her arguments, but what
happens is that you (and Jamie, too) end up getting nothing for yourself. I wonder if you
could take a different tack for a while and ask yourself this (and, later: Jamie, I’d like to
ask you to do the same): Is there anything in what Jamie is saying that is true for you?
What parts seem to strike an inner chord? Could you forget for a moment the things that
are not true and stay with those that are true?”
Sometimes group members, in an unusually open moment, make a statement that may
at some future time provide the therapist with great leverage. The thrifty therapist
underscores these comments in the group and stores them for later use. For example, one
man who was both proud of and troubled by his ability to manipulate the group with his
social charm, pleaded at one meeting, “Listen, when you see me smile like this, I’m really
hurting inside. Don’t let me keep getting away with it.” Another member, who tyrannized
the group with her tears, announced one day, “When I cry like this, I’m angry. I’m not
going to fall apart, so stop comforting me, stop treating me like a child.” Store these
moments of truth; they can be of great value if recalled later, in a constructive, supportive
manner, when the client is closed and defensive. In the previous example, you could
simply remind the member of her comment a few meetings ago and ask whether this (the
smiling to cover the pain or the self protective crying) is happening now.
Often it is useful to enlist the client more actively in establishing contracts. For
example, if a client has worked hard in a session on some important trait, I might say

something like: “Jane, you worked hard today and were very open to our feedback about
the way you mother others and the way you use that mothering to avoid facing your own
needs and pain. How did it feel? Did we push you too hard?” If the client agrees that the
work was helpful (as the client almost always does), then it is possible to nail down a
future contract by asking, “Then is it all right for us to keep pressing you, to give you
feedback whenever we note you doing this in future meetings?” This form of
“contracting” consolidates the therapeutic alliance and the mutual, collaborative nature of
the psychotherapy.19
PROCESS COMMENTARY: A THEORETICAL
OVERVIEW
It is not easy to discuss, in a systematic way, the actual practice of process illumination.
How can one propose crisp, basic guidelines for a procedure of such complexity and
range, such delicate timing, so many linguistic nuances? I am tempted to beg the question
by claiming that herein lies the art of psychotherapy: it will come as you gain experience;
you cannot, in a systematic way, come to it. To a degree, I believe this to be so. Yet I also
believe that it is possible to blaze crude trails, to provide the clinician with general
principles that will accelerate education without limiting the scope of artistry.
The approach I take in this section closely parallels the approach I used in the beginning
of this book to clarify the basic therapeutic factors in group therapy. At that time I asked
the questions: “How does group therapy help clients? In the group therapeutic process,
what is core and what is front?” This approach leads to the delineation of several basic
therapeutic factors and does not, I believe, constrain the therapist in any way in the choice
of methods to implement them.
In this section I proceed in a similar fashion. Here the issue is not how group therapy
helps but how process illumination leads to change. The issue is complex and requires
considerable attention, but the length of this discussion should not suggest that the
interpretive function of the therapist take precedence over other tasks.
First, let me proceed to view in a dispassionate manner the entire range of therapist
interventions. I ask of each intervention the simplistic but basic question, “How does this
intervention, this process-illuminating comment, help a client to change?” Underlying this
approach, is a set of basic operational patterns shared by all contemporary interpersonal
models of therapy.20
I begin by considering a series of process comments that a therapist made to a male
client over several sessions of group therapy:
1. You are interrupting me.
2. Your voice is tight, and your fists are clenched.

3. Whenever you talk to me, you take issue with me.
4. When you do that, I feel threatened and sometimes frightened.
5. I wonder if you don’t feel competitive with me and are trying to devalue me.
6. I’ve noticed that you’ve done the same thing with all the men in the group. Even
when they try to approach you helpfully, you strike out at them. Consequently,
they see you as hostile and threatening.
7. In the three meetings when there were no women present in the group, you were
more approachable.
8. I think you’re so concerned about your sexual attractiveness to women that you
view men only as competitors and deprive yourself of the opportunity of ever
getting close to a man.
9. Even though you always seem to spar with me, there seems to be another side to it.
You often stay after the group to have a word with me; you frequently look at me
in the group. And there’s that dream you described three weeks ago about the two
of us fighting and then falling to the ground in an embrace. I think you very much
want to be close to me, but somehow you’ve got closeness and eroticism entangled
and you keep pushing me away.
10. You are lonely here and feel unwanted and uncared for. That rekindles so many of
your feelings of unworthiness.
11. What’s happened in the group now is that you’ve distanced yourself, estranged
yourself, from all the men here. Are you satisfied with that? (Remember that one
of your major goals when you started the group was to find out why you haven’t
had any close men friends and to do something about that.)
Note, first of all, that the comments form a progression: they start with simple
observations of single acts and proceed to a description of feelings evoked by an act, to
observations about several acts over a period of time, to the juxtaposition of different acts,
to speculations about the client’s intentions and motivations, to comments about the
unfortunate repercussions of his behavior, to the inclusion of more inferential data
(dreams, subtle gestures), to calling attention to the similarity between the client’s
behavioral patterns in the here-and-now and in his outside social world. Inexperienced
group therapists sometimes feel lost because they have not yet developed an awareness of
this progressive sequence of interventions.21
In this progression, the comments become more inferential. They begin with sense-data
observations and gradually shift to complex generalizations based on sequences of
behavior, interpersonal patterns, fantasy, and dream material. As the comments become
more complex and more inferential, their author becomes more removed from the other
person—in short, more a therapist process-commentator. Members often make some of the
earlier statements to one another but, for reasons I have already presented, rarely make the
ones at the end of the sequence.

There is, incidentally, an exceptionally sharp barrier between comments 4 and 5. The
first four statements issue from the experience of the commentator. They are the
commentator’s observations and feelings; the client can devalue or ignore them but cannot
deny them, disagree with them, or take them away from the commentator. The fifth
statement (“I wonder if you don’t feel competitive with me and are trying to devalue me”)
is much more likely to evoke defensiveness and to close down constructive interactional
flow. This genre of comment is intrusive; it is a guess about the other’s intention and
motivation and is often rejected unless an important trusting, supportive relationship has
been previously established. If members in a young group make many comments of this
type to one another, they are not likely to develop a constructive therapeutic climate.22
Using the phrase “I wonder” of course softens it a bit. Where would we therapists be
without the use of “I wonder?”
But back to our basic question: how does this series (or any series of process comments)
help the client change? The answer is that the group therapist initiates change by escorting
the client through the following sequence:
1. Here is what your behavior is like. Through feedback and later through self-
observation, members learn to see themselves as seen by others.
2. Here is how your behavior makes others feel. Members learn about the impact of
their behavior on the feelings of other members.
3. Here is how your behavior influences the opinions others have of you. Members
learn that, as a result of their behavior, others value them, dislike them, find them
unpleasant, respect them, avoid them, and so on.
4. Here is how your behavior influences your opinion of yourself. Building on the
information gathered in the first three steps, clients formulate self-evaluations; they
make judgments about their self-worth and their lovability. (Recall Sullivan’s
aphorism that the self-concept is largely constructed from reflected self-
appraisals.)
Once this sequence has been developed and is fully understood by the individual, once
clients have a deep understanding that their behavior is not in their own best interests, that
the texture of relationships to others and to themselves is fashioned by their own actions,
then they have come to a crucial point in therapy: they have entered the antechamber of
change.
The therapist is now in a position to pose a question that initiates the real crunch of
therapy. The question, presented in a number of ways by the therapist but rarely in direct
form, is: Are you satisfied with the world you have created? This is what you do to others,
to others’ opinion of you, and to your opinion of yourself—are you satisfied with your
actions?n23
When the inevitable negative answer arrives (“No I am not satisfied with my actions”)
the therapist embarks on a many-layered effort to transform a sense of personal
dissatisfaction into a decision to change and then into the act of change. In one way or
another, the therapist’s interpretive remarks are designed to encourage the act of change.

Only a few psychotherapy theoreticians (for example, Otto Rank, Rollo May, Silvano
Arieti, Leslie Farber, Allen Wheelis, and Irvin Yalom24) include the concept of will in
their formulations, yet it is, I believe, implicit in most interpretive systems. I offer a
detailed discussion of the role of will in psychotherapy in my text Existential
Psychotherapy.25 For now, broad brush strokes are sufficient.
The intrapsychic agency that initiates an act, that transforms intention and decision into
action, is will. Will is the primary responsible mover within the individual. Although
analytic metapsychology has chosen to emphasize the irresponsible movers of our
behavior (that is, unconscious motivations and drives), it is difficult to do without the idea
of will in our understanding of change.26 We cannot bypass it under the assumption that it
is too nebulous and too elusive and, consequently, consign it to the black box of the
mental apparatus, to which the therapist has no access.
Knowingly or unknowingly, every therapist assumes that each client possesses the
capacity to change through willful choice. Using a variety of strategies and tactics, the
therapist attempts to escort the client to a crossroads where he or she can choose, willfully,
in the best interests of his or her own integrity. The therapist’s task is not to create will or
to infuse it into the client. That, of course, you cannot do. What you can do is to help
remove encumbrances from the bound or stifled will of the client.27
The concept of will provides a useful construct for understanding the procedure of
process illumination. The interpretive remarks of the therapist can all be viewed in terms
of how they bear on the client’s will. The most common and simplistic therapeutic
approach is exhortative: “Your behavior is, as you yourself now know, counter to your
best interests. You are not satisfied. This is not what you want for yourself. Damn it,
change!”
The expectation that the client will change is simply an extension of the moral
philosophical belief that if one knows the good (that is, what is, in the deepest sense, in
one’s best interest), one will act accordingly. In the words of St. Thomas Aquinas: “Man,
insofar as he acts willfully, acts according to some imagined good.”28 And, indeed, for
some individuals this knowledge and this exhortation are sufficient to produce therapeutic
change.
However, clients with significant and well-entrenched psychopathology will need much
more than sheer exhortation. The therapist, through interpretative comments, then
proceeds to exercise one of several other options that help clients disencumber their will.
The therapist’s goal is to guide clients to a point where they accept one, several, or all of
the following basic premises:
1. Only I can change the world I have created for myself.
2. There is no danger in change.
3. To attain what I really want, I must change.
4. I can change; I am potent.

Each of these premises, if fully accepted by a client, can be a powerful stimulant to
willful action. Each exerts its influence in a different way. Though I will discuss each in
turn, I do not wish to imply a sequential pattern. Each, depending on the need of the client
and the style of the therapist, may be effective independently of the others.
“Only I can change the world I have created for myself.”
Behind the simple group therapy sequence I have described (seeing one’s own behavior
and appreciating its impact on others and on oneself), there is a mighty overarching
concept, one whose shadow touches every part of the therapeutic process. That concept is
responsibility. Although it is rarely discussed explicitly, it is woven into the fabric of most
psychotherapeutic systems. Responsibility has many meanings—legal, religious, ethical. I
use it in the sense that a person is “responsible for” by being the “basis of,” the “cause of,”
the “author of” something.
One of the most fascinating aspects of group therapy is that everyone is born again,
born together in the group. In other words, each member starts off on an equal footing. In
the view of the others (and, if the therapist does a good job, in the view of oneself), each
gradually scoops out and shapes a life space in the group. Each member, in the deepest
sense of the concept, is responsible for this space and for the sequence of events that will
occur to him or her in the group.
The client, having truly come to appreciate this responsibility, must then accept, too,
that there is no hope for change unless he or she changes. Others cannot bring change, nor
can change bring itself. One is responsible for one’s past and present life in the group (as
well as in the outside world) and totally responsible for one’s future.
Thus, the therapist helps the client understand that the interpersonal world is arranged in
a generally predictable and orderly fashion, that it is not that the client cannot change but
that he or she will not change, that the client bears the responsibility for the creation of his
or her world and therefore the responsibility for its transmutation. The client must regain
or develop anew a sense of his or her own interpersonal agency in the world.
“There is no danger in change.”
These well-intentioned efforts may not be enough. The therapist may tug and tug at the
therapeutic cord and learn that individuals, even after being thus enlightened, still make no
significant therapeutic movement. In this case, therapists apply additional therapeutic
leverage by helping clients face the paradox of continuing to act contrary to their basic
interests. In a number of ways therapists must pose the question, “How come? Why do
you continue to defeat yourself?”
A common method of explaining “How come?” is to assume that there are formidable
obstacles to the client’s exercising willful choice, obstacles that prevent clients from
seriously considering altering their behavior. The presence of the obstacle is generally

inferred; the therapist makes an “as if” assumption: “You behave as if you feel some
considerable danger would befall you if you were to change. You fear to act otherwise for
fear that some calamity will befall you.” The therapist helps the client clarify the nature of
the imagined danger and then proceeds, in several ways, to detoxify, to disconfirm the
reality of this danger.
The client’s reason may be enlisted as an ally. The process of identifying and naming
the fantasized danger may, in itself, enable one to understand how far removed one’s fears
are from reality. Another approach is to encourage the client, in carefully calibrated doses,
to commit the dreaded act in the group. The fantasized calamity does not, of course,
ensue, and the dread is gradually extinguished. This is often the pivotal piece of effective
therapy. Change is probably not possible, let alone enduring, without the client’s having a
lived experience of direct disconfirmation of pathogenic beliefs. Insight alone is unlikely
to be effective. This principle cuts powerfully across different schools of therapy.†
For example, suppose a client avoids any aggressive behavior because at a deep level he
fears that he has a dammed-up reservoir of homicidal fury and must be constantly vigilant
lest he unleash it and eventually face retribution from others. An appropriate therapeutic
strategy is to help the client express aggression in small doses in the group: pique at being
interrupted, irritation at members who are habitually late, anger at the therapist for
charging him money, and so on. Gradually, the client is helped to relate openly to the other
members and to demythologize himself as a homicidal being. Although the language and
the view of human nature are different, this is precisely the same approach to change used
in systematic desensitization—a major technique of behavior therapy.
“To attain what I really want, I must change.”
Another explanatory approach used by many therapists to deal with a client who
persists in behaving counter to his or her best interests is to consider the payoffs of that
individual’s behavior. Although the person’s behavior sabotages many of his or her mature
needs and goals, at the same time it satisfies another set of needs and goals. In other
words, the client has conflicting motivations that cannot be simultaneously satisfied. For
example, a male client may wish to establish mature heterosexual relationships; but at
another, often unconscious, level, he may wish to be nurtured, to be cradled endlessly, to
avoid the abandonment that he anticipates as the punishment for his adult strivings or, to
use an existential vocabulary, to be sheltered from the terrifying freedom of adulthood.
Obviously, the client cannot satisfy both sets of wishes: he cannot establish an adult
heterosexual relationship with a woman if he also says (and much more loudly), “Take
care of me, protect me, nurse me, let me be a part of you.”
It is important to clarify this paradox for the client. We might, for example, point out:
“Your behavior makes sense if we assume that you wish to satisfy the deeper, earlier, more
primitive need.” We try to help the client understand the nature of his conflicting desires,
to choose between them, to relinquish those that cannot be fulfilled except at enormous
cost to his integrity and autonomy. Once the client realizes what he really wants (as an

adult) and that his behavior is designed to fulfill opposing growth-retarding needs, he
gradually concludes: To attain what I really want, I must change.
“I can change; I am potent.”
Perhaps the major therapeutic approach to the question “How come you act in ways
counter to your best interests?” is to offer explanation. The therapist says, in effect, “You
behave in certain fashions because … ,” and the “because” clause generally involves
motivational factors outside the client’s awareness. It is true that the previous two options
I have discussed also proffer explanation but—and I will clarify this shortly—the purpose
of the explanation (the nature of the leverage exerted on will) is quite different in the two
approaches.
What type of explanation does the therapist offer the client? And which explanations are
correct, and which incorrect? Which “deep”? Which “superficial”? It is at this juncture
that the great metapsychological controversies of the field arise, since the nature of
therapists’ explanations are a function of the ideological school to which they belong.
I think we can sidestep the ideological struggle by keeping a fixed gaze on the function
of the interpretation, on the relationship between explanation and the final product:
change. After all, our goal is change. Self-knowledge, derepression, analysis of
transference, and self-actualization—all are worthwhile, enlightened pursuits, all are
related to change, preludes to change, cousins and companions to change; and yet they are
not synonymous with change.
Explanation provides a system by which we can order the events in our lives into some
coherent and predictable pattern. To name something and to place it into a causal sequence
is to experience it as being under our control. No longer is our behavior or our internal
experience frightening, inchoate, out of control; instead, we behave (or have a particular
inner experience) because … . The “because” offers us mastery (or a sense of mastery that,
phenomenologically, is tantamount to mastery). It offers us freedom and self-efficacy.† As
we move from a position of being motivated by unknown forces to a position of
identifying and controlling those forces, we move from a passive, reactive posture to an
active, acting, changing posture.
If we accept this basic premise—that a major function of explanation in psychotherapy
is to provide the client with a sense of personal mastery—it follows that the value of an
explanation should be measured by this criterion. To the extent that it offers a sense of
potency, a causal explanation is valid, correct, or “true.” Such a definition of truth is
completely relativistic and pragmatic. It argues that no explanatory system has hegemony
or exclusive rights, that no system is the correct, fundamental one or the “deeper” (and
therefore better) one.
Therapists may offer the client any of several interpretations to clarify the same issue;
each may be made from a different frame of reference, and each may be “true.” Freudian,
interpersonal, object relations, self psychology, attachment theory, existential,

transactional analytic, Jungian, gestalt, transpersonal, cognitive, behavioral explanations—
all of these may be true simultaneously. None, despite vehement claims to the contrary,
have sole rights to the truth. After all, they are all based on imaginary, as if structures.
They all say, “You are behaving (or feeling) as if such and such a thing were true.” The
superego, the id, the ego; the archetypes; the masculine protest; the internalized objects;
the selfobject; the grandiose self and the omnipotent object; the parent, child, and adult
ego state—none of these really exists. They are all fictions, all psychological constructs
created for semantic convenience. They justify their existence only by virtue of their
explanatory powers.29
Do we therefore abandon our attempts to make precise, thoughtful interpretations? Not
at all. We only recognize the purpose and function of the interpretation. Some may be
superior to others, not because they are deeper but because they have more explanatory
power, are more credible, provide more mastery, and are therefore more useful. Obviously,
interpretations must be tailored to the recipient. In general, therapeutic interventions are
more effective if they make sense, if they are logically consistent with sound supporting
arguments, if they are bolstered by empirical observation, if they “feel” right or are
congruent and “click” with a client’s frame of reference and internal world, and if they can
be generalized and applied to many analogous situations in the client’s life.
Higher-order interpretations generally offer a novel explanation to the client for some
large pattern of behavior (as opposed to a single trait or act). The novelty of the therapist’s
explanation stems from his or her objective vantage point and unusual frame of reference,
which permits an original synthesis of data. Indeed, often the data is material that the
client has generally overlooked or that is outside his or her awareness.
If pushed, to what extent am I willing to defend this relativistic thesis? When I present
this position to students, they respond with such questions as: Does that mean that an
astrological explanation is also valid in psychotherapy? Such questions make me uneasy,
but I have to respond affirmatively. If an astrological or shamanistic or magical
explanation enhances a sense of mastery and leads to inner, personal change, then it is a
valid explanation. There is much evidence from cross-cultural psychiatric research to
support this position; the explanation must be consistent with the values and with the
frame of reference of the human community in which the client dwells. In most primitive
cultures, it is often only the magical or the religious explanation that is acceptable, and
hence valid and effective.30
Psychoanalytic revisionists make an analogous point and argue that reconstructive
attempts to capture historical “truth” are futile; it is far more important to the process of
change to construct plausible, meaningful, personal narratives.31 The past is not static:
every experienced therapist knows that the process of exploration and understanding alters
the recollection of the past. In fact, current neurobiological research tells us that every
time we access an old memory we automatically alter it according to our current context,
and the revised memory is then returned to long-term storage in place of the original
memory.32
An interpretation, even the most elegant one, has no benefit if the client does not hear it.

Therapists should take pains to review their evidence with the client and present the
explanation clearly. (Be clear: if you cannot be crystal-clear, it is likely that the
explanation is rickety or that you yourself do not understand it. The reason is not, as often
has been claimed, that you are speaking directly to the client’s unconscious.)
Do not always expect the client to accept an interpretation. Sometimes the client hears
the same interpretation many times until one day it seems to “click.” Why does it click
that one day? Perhaps the client just came across some corroborating data from new
events in the environment or from the surfacing in fantasy or dreams of some previously
unconscious material. Note also that the interpretation will not click until the client’s
relationship with the therapist is just right. For example, a group member who feels
threatened and competitive with the therapist is unlikely to be helped by any interpretation
(except one that clarifies the transference). Even the most thoughtful interpretation will
fail because the client may feel defeated or humiliated by the proof of the therapist’s
superior perceptivity. An interpretation becomes maximally effective only when it is
delivered in a context of acceptance and trust.
Sometimes a client will accept from another member an interpretation that he or she
would not accept from the therapist. (Remember, group members are entirely capable of
making interpretations as useful as those of the therapists, and members will be receptive
to these interpretations provided the other member has accepted the client role and does
not offer interpretations to acquire prestige, power, or a favored position with the leader.)
A comprehensive discussion of the types of effective interpretations would require
describing the vast number of explanatory schools and group therapy models—a task well
beyond the scope of this book.33 However, three venerable concepts are so deeply
associated with interpretation that they deserve coverage here:
1. The use of the past
2. Group-as-a-whole process commentary
3. Transference
I will discuss the first two in the remainder of this chapter. So many interpretative
systems involve transference (indeed, traditional analytic theory decrees that only the
transference interpretation can be effective) that I have devoted the next chapter entirely to
the issue of transference and transparency.
THE USE OF THE PAST
Too often, explanation is confused with “originology” (the study of origins). Although, as
I have discussed, an explanatory system may effectively postulate a “cause” of behavior
from any of a large number of perspectives, many therapists continue to believe that the
“real,” the “deepest,” causes of behavior are only to be found in the past. This position
was staunchly defended by Freud, a committed psychosocial archaeologist. To the very

end of his life, he relinquished neither his search for the primordial (that is, the earliest)
explanation nor his tenacious insistence that successful therapy hinges on the excavation
of the earliest layers of life’s memories. The idea that the present is only a small fraction
of the individual’s life and that contemporary life is shaped by the overwhelmingly large
contributions made by the past is powerfully embedded in the Western world’s view of
time.34 This view understandably results in an emphasis on the past in traditional
psychodynamic textbooks35 of group therapy.
However, the powerful and unconscious factors that influence human behavior are by
no means limited to the past. Current analytic theory makes a distinction between the past
unconscious (the child within the adult) and the present unconscious (the currently
existing unconscious thoughts, fantasies, and impulses that influence our feelings and
actions). 36 Furthermore, as I shall discuss, the future, as well as the past and the present,
is also a significant determinant of behavior.
The past may affect our behavior through pathways fully described by traditional
psychoanalytic theorists and by learning theorists (strange bedfellows). However, the “not
yet,” the future, is a no less powerful determinant of behavior, and the concept of future
determinism is fully defensible. We have at all times within us a sense of purpose, an
idealized self, a series of goals for which we strive, a death toward which we veer. These
factors, both conscious and unconscious, all arch into the future and profoundly influence
our behavior. Certainly the knowledge of our isolation, our destiny, and our ultimate death
deeply influences our conduct and our inner experience. Though we generally keep them
out of awareness, the terrifying contingencies of our existence play upon us without end.
We either strive to dismiss them by enveloping ourselves in life’s many diversions, or we
attempt to vanquish death by faith in an afterlife or by striving for symbolic immortality in
the form of children, material monuments, and creative expression. In addition to the
explanatory potency of the past and the future, there is a third temporal concept that
attempts to explain behavior: the Galilean concept of causality, which focuses on the
present—on the impact of current forces.
In summary, explanations ensue from the exploration of the concentric rings of
conscious and unconscious current motivations that envelop our clients. Take one
example: clients may have a need to attack, which covers a layer of dependency wishes
that they do not express for fear of rejection. Note that we need not ask how they got to be
so dependent. In fact, the future (a person’s anticipation of rejection) plays a more central
role in the interpretation. Thus, as we hurtle through space, our behavioral trajectory may
be thought of as triply influenced: by the past—the nature and direction of the original
push; by the future—the goal that beckons us; and by the present—the current field forces
operating upon it. Consider this clinical example:
• Two clients, Ellen and Carol, expressed strong sexual feelings toward the male
therapist of the group. (Both women, incidentally, had histories—indeed, chief
complaints—of masochistic sexual gratification.) At one meeting, they discussed
the explicit content of their sexual fantasies about the therapist. Ellen fantasized
her husband being killed; herself having a psychotic breakdown; the therapist

hospitalizing her and personally nurturing her, rocking her, and caring for all her
bodily needs. Carol had a different set of fantasies. She wondered whether the
therapist was well cared for at home. She frequently fantasized that something
happened to his wife and that she would care for him by cleaning his house and
cooking his meals.
The shared sexual attraction (which, as the fantasies indicate, was not genital-
sexual) had for Ellen and Carol very different explanations. The therapist pointed
out to Ellen that throughout the course of the group, she had suffered frequent
physical illness or severe psychological relapses. He wondered whether, at a deep
level, she felt as though she could get his love and that of the other members only
by a form of selfimmolation. If this was the case, however, it never worked. More
often than not, she discouraged and frustrated others. Even more important was
the fact that as long as she behaved in ways that caused her so much shame, she
could not love herself. He emphasized that it was crucial for her to change the
pattern, because it defeated her in her therapy: she was afraid to get better, since
she felt that to do so would entail an inevitable loss of love and nurturance.
In his comments to Carol, the therapist juxtaposed several aspects of her
behavior: her self-derogation, her refusal to assume her rights, her inability to get
men interested in her. Her fantasy of taking care of the therapist was illustrative of
her motivations: she believed that if she could be self-sacrificing enough, if she
could put the therapist deeply into her debt, then she should, in reciprocal fashion,
receive the love she sought. However, Carol’s search for love, like Ellen’s, always
failed. Her eternal ingratiation, her dread of self-assertion, her continued self-
devaluation succeeded only in making her appear dull and spiritless to those
whose regard she most desired. Carol, like Ellen, whirled about in a vicious circle
of her own creation: the more she failed to obtain love, the more frantically she
repeated the same self-destructive pattern—the only course of behavior she knew
or dared to enact. It was a neatly contained, self-reinforcing, and self-defeating
cycle.
So here we have two clients with a similar behavioral pattern: “sexual” infatuation with
the therapist. Yet the therapist offered two different interpretations reflecting two different
dynamic pathways to psychological masochism. In each, the therapist assembled several
aspects of the client’s behavior in the group as well as fantasy material and suggested that,
if certain “as if” assumptions were made (for example, that Ellen acted as if she could
obtain the therapist’s love only by offering herself as severely damaged, and that Carol
acted as if she could obtain his love only by so serving him and thus place him in her
debt), then the rest of the behavior “made sense.”
Both interpretations were potent and had a significant impact on future behavior. Yet
neither broached the question “How did you get to be that way? What happened in your
earlier life to create such a pattern?” Both dealt instead with currently existing patterns:
the desire for love, the conviction that it could be obtained only in certain ways, the
sacrifice of autonomy, the resulting shame, the ensuing increased need for a sign of love,

and so on.
One formidable problem with explanations based on the distant past is that they contain
within them the seeds of therapeutic despair. Thus the paradox: if we are fully determined
by the past, whence comes the ability to change? As is evident in such later works as
Analysis Terminable and Interminable, Freud’s uncompromising deterministic view led
him to, but never through, this Gordian knot.
The past, moreover, no more determines the present and the future than it is determined
by them. The past exists for each of us only as we constitute it in the present against the
horizon of the future. Jerome Frank remind us that clients, even in prolonged therapy,
recall only a minute fraction of their past experience and may selectively recall and
synthesize the past so as to achieve consistency with their present view of themselves.37 In
the same way that a client (as a result of therapy) alters her self-image, she may
reconstitute the past. She may, for example, recall long-forgotten positive experiences with
parents; she may humanize them and, rather than experiencing them solipsistically (as
figures who existed by virtue of their service to herself), begin to understand them as
harried, well-intentioned individuals struggling with the same overwhelming facts of the
human condition that she faces herself. Once she reconstitutes the past, a new past can
further influence her self-appraisal; however, it is the reconstitution, not simply the
excavation, of the past that is crucial. Note an allied research finding: effective therapy
generates further recollection of past memories, which in turn further modify the
reconstitution of the past.38
If explanations are not to be sought from an originological perspective, and if the most
potent focus of the group is the ahistorical here-and-now, does the past therefore play no
role at all in the group therapeutic process? By no means! The past is an incessant visitor
to the group and an even more incessant visitor to the inner world of each of the members
during the course of therapy. Not infrequently, for example, a discussion of the past plays
an important role in the development of group cohesiveness by increasing intermember
understanding and acceptance.
The past is often invaluable in conflict resolution. Consider, for example, two members
locked in a seemingly irreconcilable struggle, each of whom finds many aspects of the
other repugnant. Often a full understanding of the developmental route whereby each
arrived at his or her particular viewpoint can rehumanize the struggle. A man with a regal
air of hauteur and condescension may suddenly seem understandable, even winsome,
when we learn of his immigrant parents and his desperate struggle to transcend the
degradation of a slum childhood. Individuals benefit through being fully known by others
in the group and being fully accepted; knowing another’s process of becoming is a rich
and often indispensable adjunct to knowing the person.
An ahistorical here-and-now interactional focus is never fully attainable. Discussions of
future anticipations, both feared and desired, and of past and current experiences, are an
inextricable part of human discourse. What is important in group therapy is the accent; the
past is the servant, not the master. It is important in that it explicates the current reality of
the client, who is in the process of unfolding in relation to the other group members. As

Rycroft states, “It makes better sense to say that the analyst makes excursions into
historical research in order to understand something which is interfering with his present
communication with the patient (in the same way that a translator might turn to history to
elucidate an obscure text) than to say that he makes contact with the patient in order to
gain access to biographical data.”39
To employ the past in this manner involves an anamnestic technique differing from that
often employed in individual therapy. Rather than a careful global historical survey, group
therapists periodically attempt a sector analysis in which they explore the development of
some particular interpersonal stance. Consequently, many other aspects of a client’s past
remain undiscussed in group therapy. It is not uncommon, for example, for group
therapists to conclude a course of successful therapy with a client and yet be unfamiliar
with many significant aspects of the individual’s early life.
The lack of explicit discussion of the past in the ongoing therapy group does not
accurately reflect the consideration of the past occurring within each client during therapy.
The intensive focus on the here-and-now does not, of course, have as its final goal the
formation of enduring relationships among group members. That is a way station, it is a
dress rehearsal for the work that must be done with family and friends—the truly
important individuals in a client’s life.
At the end of therapy, clients commonly report significant attitudinal improvements in
relationships that have rarely been explicitly discussed in the group. Many of these
involve family members with whom one has had a relationship stretching far back into the
past. Many clients, in fact, change their feelings about family members who are long dead.
So the past plays a role in the working-through process, and the therapist should be aware
of this silent, important homework. Yet it is an implicit role. To make repetitive use of the
group meeting for explicit discussion of the past would sacrifice the therapeutic potency of
the here-and-now interactional focus.
GROUP – AS – A – WHOLE PROCESS COMMENTARY
Some group leaders choose to focus heavily on group-as-a-whole phenomena. In their
comments, these leaders frequently refer to the “group” or “we” or “all of us.” They
attempt to clarify the relationship between the group and its primary task, or between the
group and the leader or one of its members, a subgroup, or some shared concern. Recall,
for a moment, the “parenthood is degrading” incident described earlier in this chapter. In
that incident the therapist had many process commentary options, some of which were
group-as-a-whole explanations. He might, for example, have raised the issue of whether
the “group” needed a scapegoat and whether, with Kate gone, Burt filled the scapegoat
role; or whether the “group” was actively avoiding an important issue—that is, their guilty
pleasure and fears about Kate’s departure.
Throughout this text I weave in comments related to group-as-a-whole phenomena: for

example, norm setting, the role of the deviant, scapegoating, emotional contagion, role
suction, subgroup formation, group cohesiveness, group pressure, the regressive
dependency fostered by group membership, the group’s response to termination, to the
addition of new members, to the absence of the leader, and so on. In addition to these
common group phenomena, earlier editions of this book described some comprehensive
group-as-a-whole approaches, particularly the work of Wilfred Bion, which offers an
elaborate description of the psychology of groups and the unconscious forces that obstruct
effective group functioning. 40 His approach, also known as the Tavistock approach,
persists as a useful model for understanding group-as-a-whole dynamics. Its emphasis,
however, on an inscrutable, detached, leader who serves as “conductor” of the group and
limits his participation solely to group-as-a-whole interpretations has resulted in the
abandonment of the Tavistock approach for group psychotherapy. Tavistock conferences,
however, are still used as an educational vehicle to inform participants about the nature of
group forces, leadership, and authority. (See www.yalom.com for fourth edition discussion
of Bion’s contributions.)
There is little question of the importance of group-as-a-whole phenomena. All group
leaders would agree that inherent forces in a group significantly influence behavior;
individuals behave differently in a group than they do in dyads (a factor that, as I will
discuss in chapter 9, confounds the selection of group therapy members). There is wide
agreement that an individual’s behavior cannot be fully understood without an
appreciation of his or her social and environmental context. But there remains the question
of how best to apply this knowledge in the course of the therapy group. Examining the
rationale of group-as-a-whole commentary provides some guidelines.
Rationale of Group-as-a-Whole Process Commentary
Group-as-a-whole phenomena influence the clinical course of the group in two significant
ways: they can act in the service of the group, and they can impede effective group
therapy.
Group-as-a-whole forces acting in the service of therapy. I have, throughout this text,
already considered many therapeutic uses of group-as-a-whole phenomena: for example,
many of the major therapeutic factors, such as cohesiveness—the esprit de corps of the
entire group—obviously relate to group-as-a-whole properties, and therapists are, in fact,
harnessing group-as-a-whole forces when they facilitate the development of cohesiveness.
However, it does not follow that the leader must make explicit group-as-a-whole
comments.
Group-as-a-whole forces impeding therapy. There are times when group-as-a-whole
processes significantly impede therapy, and then commentary is necessary. In other words,
the purpose of a group-as-a-whole interpretation is to remove some obstacle that has
arisen to obstruct the progress of the entire group.41 The two common types of obstacle
are anxiety-laden issues and antitherapeutic group norms.

http://www.yalom.com

Anxiety-Laden Issues
Often some issue arises in the group that is so threatening that the members refuse to
confront the problem and take some evasive action. This evasion takes many forms, all of
which are commonly referred to as group flight—a regression from the group’s normal
functions. Here is a clinical example of flight from an anxiety-laden issue:
• Six members were present at the twenty-fifth group meeting; one member, John,
was absent. For the first time, and without previous mention, one of the members,
Mary, brought her dog to the meeting. The group members, usually animated and
active, were unusually subdued and nonproductive. Their speech was barely
audible, and throughout the meeting they discussed safe topics on a level of
impersonality appropriate to a large social gathering or cocktail party. Much of
the content centered on study habits (three of the members were graduate
students), examinations, and teachers (especially their untrustworthiness and
defects). Moreover, the senior member of the group discussed former members who
had long since departed from the group—the “good old days” phenomenon.
Mary’s dog (a wretched, restless creature who spent most of the group session
noisily licking its genitals) was never mentioned.
Finally, the therapist, thinking he was speaking for all the group members,
brought up the issue of Mary’s having brought her dog to the meeting. Much to the
therapist’s surprise, Mary—a highly unpopular, narcissistic member—was
unanimously de fended. Everyone denied that the dog was in any way distracting,
leaving the protesting therapist dangling in the wind.
The therapist considered the entire meeting as a “flight” meeting and, accordingly,
made appropriate group-as-a-whole interpretations, which I will discuss shortly. But first,
what is the evidence that such a meeting is in flight? And flight from what? First, consider
the age of the group. In a young group, meeting, say, for the third time—such a session
may be a manifestation not of resistance but of the group members’ uncertainty about their
primary task and of their groping to establish procedural norms. However, this group had
already met for many months and had consistently operated at a more mature level.
It becomes very evident that the group was in a flight mode when we examine the
preceding group meeting. At that meeting, John, the member absent from the meeting
under consideration, had been twenty minutes late and happened to walk down the
corridor at the precise moment when a student opened the door of the adjoining
observation room in order to enter it. For the few seconds while the door was open, John
heard the voices of the other group members and saw a room full of observers viewing the
group; moreover, the observers at that moment happened to be giggling at some private
joke. John, like all the group members, had of course been told that the group was being
observed by students. Nevertheless, this shocking and irreverent confirmation stunned
him. When John, in the last moments of the meeting, was finally able to discuss it with the
other members, they were equally stunned. John, as I mentioned, did not show up for the
next session.

This event was a catastrophe of major proportions for the entire group—as it would be
for any group. It raised serious questions in the minds of the members. Was the therapist to
be trusted? Was he, like his colleagues in the observation room, inwardly giggling at
them? Was anything he said genuine? Was the group, once perceived as a deeply human
encounter, in fact a sterile, contrived, laboratory specimen being studied dispassionately
by a therapist who probably felt closer allegiance to “them” (the others, the observers)
than to the group members?
Despite—or, rather, because of—the magnitude of these painful group issues, the group
declined to confront the matter. Instead, it engaged in flight behavior, which now begins to
be understandable. Exposed to an outside threat, the group members banded tightly
together for protection. They spoke softly about safe topics so as to avoid sharing anything
with the outside menace (the observers and, through association, the therapist). The
therapist was unsupported when he asked about the obviously distracting behavior of
Mary’s dog. The “good old days” was a reference to and yearning for those bygone times
when the group was pure and verdant and the therapist could be trusted. The discussion of
examinations and untrustworthy teachers was also a thinly veiled expression of attitudes
toward the therapist.
The precise nature and timing of the intervention is largely a matter of individual style.
Some therapists, myself included, tend to intervene when they sense the presence of group
flight even though they do not clearly understand its source. I may, for example, comment
that I feel puzzled or uneasy about the meeting and inquire, “Is there something the group
is not talking about today?” or “Is the group avoiding something?” or “I have a sense
there’s a ‘hidden agenda’ today; could we talk about this?”
I may increase the power of my inquiry by citing the evidence for such a conclusion—
for example, the whispering, the shift toward neutral topics and a noninteractive,
impersonal mode of communication, my experience of being left out or of being deserted
by the others when I mentioned the obvious distraction of the dog. Furthermore, I might
add that the group is strangely avoiding all discussion both of the previous meeting and of
John’s absence today. In one way or another, however, the problems of the group as a
whole must be addressed before any meaningful interpersonal work can resume.
In this clinical example, would we be satisfied merely with getting the group back on
the track of discussing more meaningful personal material? No! More is needed: the issues
being avoided were too crucial to the group’s existence to be left submerged. This
consideration was particularly relevant in this group, whose members had insufficiently
explored their relationship to me. Therefore, I repeatedly turned the group’s attention back
to the main issue (their trust and confidence in me) and tried not to be misled by substitute
behavior—for example, the group’s offering another theme for discussion, perhaps even a
somewhat charged one. My task was not simply to circumvent the resistance, to redirect
the group to work areas, but to plunge the members into the source of the resistance—in
other words, not around anxiety, but through it.
Another clue to the presence and strength of resistance is the group’s response to
therapists’ resistance-piercing commentary. If therapists’ comments, even when repeated,

fall on deaf ears, if therapists feel ignored by the group, if they find it extraordinarily
difficult to influence the meeting, then it is clear that the resistance is powerful and that
the group needs to be addressed as well as the individual members. It is not an easy
undertaking. It is anxiety-provoking to buck the entire group, and therapists may feel
deskilled in such meetings.
The group may also avoid work by more literal flight—absence or tardiness. Whatever
the form, however, the result is the same: in the language of the group dynamicist,
locomotion toward the attainment of group goals is impeded, and the group is no longer
engaged in its primary task.
Not uncommonly, the issue precipitating the resistance is discussed symbolically. I have
seen groups deal with their uneasiness about observers metaphorically by long discussions
about other types of confidentiality violation: for example, public posting of grades for a
school course, family members opening one another’s mail, and invasive credit company
computers. Discomfort about the therapist’s absence may prompt discussions of parental
inaccessibility or death or illness. Generally, the therapist may learn something of what is
being resisted by pondering the question “Why is this particular topic being discussed, and
why now?”
An experience in a therapy group at the height of the 2003 SARS (Severe Acute
Respiratory Syndrome) epidemic may be illustrative.
• A group in a partial hospitalization program for depressed seniors was canceled
for several weeks and finally reconvened, but with the proviso that all participants
were required to wear uncomfortable and oppressive face masks (heeding the
recommendation of infection control) that obscured nonverbal communication. The
meeting was characterized by unusually hostile comments about deprivations:
uncaring adult children, incompetent public health officials, unavailable,
neglectful therapists. Soon the members began to attack one another and the group
seemed on the brink of total disintegration.
The therapist, also struggling with the restrictive mask, asked for a “process
check”—that is, he asked the group to stop for a moment and reflect on what was
happening so far in the meeting. The members all agreed that they hated what the
SARS crisis had done to their group. The masks not only were physically irritating,
but they also blocked them from feeling close to others in the group. They realized,
too, that the generalized anger in the group was misplaced, but they did not know
what to do with their strong feelings.
The therapist made a group-as-a-whole interpretation: “There’s a sort of
paradox here today: it’s evident that you cherish this group and are angry at being
deprived of it, yet, on the other hand, the anger you experience and express
threatens the warm supportive group atmosphere you so value.” A lot of head
nodding followed the therapist’s interpretation, and the anger and divisiveness
soon dissipated.

Antitherapeutic Group Norms
Another type of group obstacle warranting a group-as-a-whole interpretation occurs when
antitherapeutic group norms are elaborated by the group. For example, a group may
establish a “take turns” format in which an entire meeting is devoted, sequentially, to each
member of the group. “Taking turns” is a comfortable or convenient procedure, but it is an
undesirable norm, because it discourages free interaction in the here-and-now.
Furthermore, members are often forced into premature self-disclosure and, as their turn
approaches, may experience extreme anxiety or even decide to terminate therapy. Or a
group may establish a pattern of devoting the entire session to the first issue raised in that
session, with strong invisible sanctions against changing the subject. Or there may be a
“Can you top this?” format in which the members engage in a spiraling orgy of self-
disclosure. Or the group may develop a tightly knit, closed pattern that excludes outlying
members and does not welcome new ones.
To intervene effectively in such instances, therapists may need to make a group-as-a-
whole interpretation that clearly describes the process and the deleterious effects the
taking-turns format has on the members or on the group and emphasizes that there are
alternatives to this mode of opening each meeting.
Frequently a group, during its development, bypasses certain important phases or never
incorporates certain norms into its culture. For example, a group may develop without
ever going through a period of challenging or confronting the therapist. Or a group may
develop without a whisper of intermember dissension, without status bids or struggles for
control. Or a group may meet at length with no hint of real intimacy or closeness arising
among the members. Such avoidance is a collaborative result of the group members
implicitly constructing norms dictating this avoidance.
Therapists who sense that the group is providing a one-sided or incomplete experience
for the members often facilitate the progress of the group work by commenting on the
missing aspect of the group’s life. (Such an intervention assumes, of course, that there are
regularly recurring, predictable phases of small group development with which the
therapist is familiar—a topic I will discuss in chapter 11.)
The Timing of Group Interventions
For pedagogical reasons, I have discussed interpersonal phenomena and group-as-a-whole
phenomena as though they were quite distinct. In practice, of course, the two often
overlap, and the therapist is faced with the question of when to emphasize the
interpersonal aspects of the transaction and when to emphasize the group-as-a-whole
aspects. This matter of clinical judgment cannot be neatly prescribed. As in any
therapeutic endeavor, judgment develops from experience (particular supervised
experience) and from intuition. As Melanie Klein stated, “It is a most precious quality in
an analyst to be able at any moment to pick out the point of urgency.”42

The point of urgency is far more elusive in group therapy than in individual treatment.
As a general rule, however, an issue critical to the existence or functioning of the entire
group always takes precedence over narrower interpersonal issues. As an illustration, let
me return to the group that engaged in whispering, discussion of neutral topics, and other
forms of group flight during the meeting after a member had inadvertently discovered the
indiscreet group observers. In that meeting, Mary, who had been absent at the previous
meeting, brought her dog. Under normal circumstances, this act would clearly have
become an important group issue: Mary had consulted neither with the therapist nor with
other members about bringing her dog to the group; she was, because of her narcissism, an
unpopular member, and her act was representative of her insensitivity to others. However,
in this meeting there was a far more urgent issue—one threatening the entire group—and
the dog was discussed not from the aspect of facilitating Mary’s interpersonal learning but
as he was used by the group in its flight. Only later, after the obstacle to the group’s
progress had been worked through and removed, did the members return to a meaningful
consideration of their annoyance about Mary bringing the dog.
To summarize, group-as-a-whole forces are continuously at play in the therapy group.
The therapist needs to be aware of them in order to harness group forces in the service of
therapy and to counter them when they obstruct therapy.†

Chapter 7
THE THERAPIST: TRANSFERENCE AND
TRANSPARENCY
Having discussed the mechanisms of therapeutic change in group therapy, the tasks of the
therapist, and the techniques by which the therapist accomplishes these tasks, I turn in this
chapter from what the therapist must do in the group to how the therapist must be. Do you,
as therapist, play a role? To what degree are you free to be yourself? How “honest” can
you be? How much transparency can you permit yourself?
Any discussion of therapist freedom should begin with transference, which can be either
an effective therapeutic tool or a set of shackles that encumbers your every movement. In
his first and extraordinarily prescient essay on psychotherapy (the final chapter of Studies
on Hysteria [1895]), Freud noted several possible impediments to the formation of a good
working relationship between client and therapist.1 Most of them could be resolved easily,
but one stemmed from deeper sources and resisted efforts to banish it from the therapeutic
work. Freud labeled this impediment transference, since it consisted of attitudes toward
the therapist that had been “transferred” from earlier attitudes toward important figures in
the client’s life. These feelings toward the therapist were “false connections”—new
editions of old impulses.
Freud soon realized, however, that transference was far from being an impediment to
therapy; on the contrary, if used properly, it could be the therapist’s most effective tool.2
What better way to help the clients recapture the past than to allow them to reexperience
and reenact ancient feelings toward parents through the current relationship to the
therapist? Furthermore, the intense and conflicted relationship that often develops with the
therapist, which he termed the transference neurosis, was amenable to reality testing; the
therapist could treat it and, in so doing, simultaneously treat the infantile conflict.
Although some of these terms may seem dated, many of today’s psychotherapeutic
approaches, including cognitive therapy, acknowledge a concept similar to transference
but refer to it as the client’s “schema.”3
Although considerable evolution in theory and technique has occurred in
psychoanalysis over the past half century, until recently some basic principles regarding
the role of transference in psychoanalytic therapy have endured with relatively little
change:4
1. Analysis of transference is the major therapeutic task of the therapist.
2. Because the development (and then the resolution) of transference is crucial, it is
important that therapists facilitate its development by remaining opaque, so that
the client can encloak them in transferred feelings and attitudes, much as one
might dress a mannequin after one’s own fancy. (This is the rationale behind the
“blank screen” role of the analyst, a role that enjoys little currency these days even
among traditional analysts.)

3. The most important type of interpretation the therapist can make is one that
clarifies some aspect of transference. (In the early days of analysis the transference
interpretation was referred to as the “mutative interpretation.”)
In recent decades, however, many analysts have shifted their assumptions as they have
recognized the importance of other factors in the therapeutic process. Judd Marmor, a
prominent American analyst, anticipated this evolution in a 1973 article in which he
wrote, “Psychoanalysts have begun, in general, to feel more free to enter into active
communicative exchanges with patients instead of remaining bound to the incognito
‘neutral mirror’ model of relative silence and impassivity.”5 More recently, Stephen
Mitchell, a leader in relational approaches to mainstream psychoanalysis commented:
Many patients are now understood to be suffering not from conflictual infantile
passions that can be tamed and transformed through reason and understanding but
from stunted personal development. Deficiencies in caregiving in the earliest years
are understood to have contributed to interfering with the emergence of a fully
centered, integrated sense of self, of the patient’s own subjectivity. What the
patient needs is not clarification or insight so much as a sustained experience of
being seen, personally engaged, and, basically valued and cared about.6
Mitchell and many others argue that the “curative” factor in both individual and group
therapy is the relationship, which requires the therapist’s authentic engagement and
empathic attunement to the client’s internal emotional and subjective experience.†7 Note
that this new emphasis on the nature of the relationship means that psychotherapy is
changing its focus from a one-person psychology (emphasizing the client’s pathology) to a
two-person psychology (emphasizing mutual impact and shared responsibility for the
relationship).†8 In this model, the therapist’s emotional experience in the therapy is a
relevant and powerful source of data about the client. How to make wise use of this data
will be elaborated shortly. Few would quarrel with the importance of the development,
recognition, and resolution of transference in individual, dynamically oriented therapy.o
Psychoanalysts disagree about the degree of permissible therapist disclosure—ranging
from extensive disclosure9 to complete opaqueness.10 But they do agree that transference
is “inappropriate, intense, ambivalent, capricious, and tenacious”11 and agree also about
the centrality of the transference and the key role of the interpretation of transference in
analytic treatment. The difference between analytic schools centers mainly on whether
“transference is everything or almost everything.”12
In group therapy the problem is not the importance of transference work; it is the
priority of this work relative to other therapeutic factors in the treatment process. The
therapist cannot focus solely on transference and at the same time perform the variety of
tasks necessary to build a group that can make use of the important group therapeutic
factors.
The difference between group therapists who consider the resolution of therapist-client
transference as the paramount therapeutic factor13 and those who attach equal importance
to the interpersonal learning that ensues from relationships between members and from

other therapeutic factors is more than theoretical: in practice, they use markedly different
techniques. The following vignettes from a group led by a formal British analyst who
made only transference interpretations illustrate this point:
• At the twentieth meeting, the members discussed at great length the fact that they
did not know one another’s first names. They then dealt with the general problem
of intimacy, discussing, for example, how difficult it was to meet and really know
people today. How does one make a really close friend? Now, on two occasions
during this discussion, a member had erred or forgotten the surname of another
member. From this data the group leader made the transference interpretation that
by forgetting the others’ names, the members were expressing a wish that all the
other members would vanish so that each could have the therapist’s sole attention.
• In another session, two male members were absent, and four women members
bitterly criticized the one male client present, who was gay, for his detachment and
narcissism, which precluded any interest in the lives or problems of others. The
therapist suggested that the women were attacking the male client because he did
not desire them sexually. Moreover, he was an indirect target; the women really
wanted to attack the therapist for his refusal to engage them sexually.
In each instance, the therapist selectively attended to the data and, from the vantage
point of his particular conception of the paramount therapeutic factor—that is,
transference resolution—made an interpretation that was pragmatically correct, since it
focused the members’ attention on their relationship with the leader. However, in my view,
these therapist-centered interpretations are incomplete, for they deny important
intermember relationships. In fact, in the first vignette, the members, in addition to their
wish for the therapist’s sole attention, were considerably conflicted about intimacy and
about their desires and fears of engaging with one another. In the second vignette, the male
client had in fact been self-absorbed and detached from the other members of the group,
and it was exceedingly important for him to recognize and understand his behavior.
Any mandate that limits group therapists’ flexibility renders them less effective. I have
seen some therapists hobbled by a conviction that they must at all times remain totally
anonymous and neutral, others by their crusade to be at all times totally “honest” and
transparent, and still others by the dictum that they must make interpretations only of
transference or only of mass group phenomena, or, even more stringently, only of mass
group transference.
The therapist’s approach to the group can amplify or moderate the expression of
members’ transferences. If the therapist emphasizes his centrality, the group will become
more regressive and dependent. In contrast, if the therapist values the peer interactions and
peer transferences as primary expressions and not merely as displacements from the
therapist, then the intensity of the transference experience in the group will be better
modulated.14
In this chapter I make the following points about transference:
1. Transference does occur in therapy groups; indeed, it is omnipresent and radically

influences the nature of the group discourse.
2. Without an appreciation of transference and its manifestations, the therapist will
often not be able to understand fully the process of the group.
3. Therapists who ignore transference considerations may seriously misunderstand
some transactions and confuse rather than guide the group members; therapists
who attend only to the transference aspects of their relationships with members
may fail to relate authentically to them.
4. There are clients whose therapy hinges on the resolution of transference distortion;
there are others whose improvement will depend on interpersonal learning
stemming from work not with the therapist but with another member, around such
issues as competition, exploitation, or sexual and intimacy conflicts; and there are
many clients who choose alternative therapeutic pathways in the group and derive
their primary benefit from other therapeutic factors entirely.
5. Transference distortions between group members can be worked with as
effectively, and perhaps even more effectively, than transference reactions to the
therapist.15
6. Attitudes toward the therapist are not all transference based: many are reality
based, and others are irrational but flow from other sources of irrationality inherent
in the dynamics of the group. (As Freud recognized, not all group phenomena can
be explained on the basis of individual psychology.)16
7. By maintaining flexibility, you may make good therapeutic use of these irrational
attitudes toward you, without at the same time neglecting your many other
functions in the group.
TRANSFERENCE IN THE THERAPY GROUP
Every client, to a greater or lesser degree, perceives the therapist incorrectly because of
transference distortions, sometimes even before beginning therapy. One psychiatrist tells
the story of going out to meet a new client in the waiting room and having the client
dispute that the therapist was who he said he was because he was so physically different
from the client’s imaginings of him.17 Few clients are entirely conflict free in their
attitudes toward such issues as parental authority, dependency, God, autonomy, and
rebellion—all of which are often personified in the person of the therapist. These
distortions are continually at play under the surface of the group discourse. Indeed, hardly
a meeting passes without some clear token of the powerful feelings evoked by the
therapist.
Witness the difference in the group when the therapist enters. Often the group may have
been engaged in animated conversation only to lapse into heavy silence at the sight of the

therapist. (Someone once said that the group therapy meeting officially begins when
suddenly nothing happens!) The therapist’s arrival not only reminds the group of its task
but also evokes early constellations of feelings in each member about the adult, the
teacher, the evaluator. Without the therapist, the group feels free to frolic; the therapist’s
presence is experienced as a stern reminder of the responsibilities of adulthood.
Seating patterns often reveal some of the complex and powerful feelings toward the
leader. Frequently, the members attempt to sit as far away from you as possible. As
members filter into the meeting they usually occupy distant seats, leaving the seats on
either side of the therapist as the penalty for late arrivals; a paranoid client often takes the
seat directly opposite you, perhaps in order to watch you more closely; a dependent client
generally sits close to you, often on your right. If co-therapists sit close to each other with
only one vacant chair between them, you can bet it will be the last chair occupied. One
member, after months of group therapy, still described a feeling of great oppression when
seated between the therapists.
Over several years, for research purposes, I asked group members to fill out a
questionnaire after each meeting. One of their tasks was to rank-order every member for
activity (according to the total number of words each spoke). There was excellent
intermember reliability in their ratings of the other group members but exceedingly poor
reliability in their ratings of the group therapist. In the same meetings some clients rated
the therapist as the most active member, whereas others considered him the least active.
The powerful and unrealistic feelings of the members toward the therapist prevented an
accurate appraisal, even on this relatively objective dimension.
One client, when asked to discuss his feelings toward me, stated that he disliked me
greatly because I was cold and aloof. He reacted immediately to his disclosure with
intense discomfort. He imagined possible repercussions: I might be too upset by his attack
to be of any more help to the group; I might retaliate by kicking him out of the group; I
might humiliate him by mocking him for some of the lurid sexual fantasies he had shared
with the group; or I might use my psychiatric wizardry to harm him in the future.
On another occasion many years ago, a group noted that I was wearing a copper
bracelet. When they learned it was for tennis elbow, their reaction was extreme. They felt
angry that I should be superstitious or ascribe to any quack cures. (They had berated me
for months for being too scientific and not human enough!) Some suggested that if I
would spend more time with my clients and less time on the tennis court, everyone would
be better off. One woman, who idealized me, said that she had seen copper bracelets
advertised in a local magazine, but guessed that mine was more special—perhaps
something I had bought in Switzerland.
Some members characteristically address all their remarks to the therapist, or speak to
other members only to glance furtively at the therapist at the end of their statement. It is as
though they speak to others in an attempt to reach the therapist, seeking the stamp of
approval for all their thoughts and actions. They forget, as it were, their reasons for being
in therapy: they continuously seek to gain conspiratorial eye contact; to be the last to leave
the session; to be, in a multitude of ways, the therapist’s favorite child.

One middle-aged woman dreamed that the group therapy room was transformed into
my living room, which was bare and unfurnished. The other group members were not
there; instead, the room was crowded with my family, which consisted of several sons. I
introduced her to them, and she felt intense warmth and pleasure. Her association to the
dream was that she was overjoyed at the thought that there was a place for her in my
home. Not only could she furnish and decorate my house (she was a professional interior
designer) but, since I had only sons (in her dream), there was room for a daughter.
Transference is so powerful and so ubiquitous that the dictum “the leader shall have no
favorites” seems to be essential for the stability of every working group. Freud suggested
that group cohesiveness, curiously, derives from the universal wish to be the favorite of
the leader and the mutual identifications the group members make with the idealized
leader.18 Consider the prototypic human group: the sibling group. It is rife with intense
rivalrous feelings: each child wishes to be the favorite and resents all rivals for their
claims to parental love. The older child wishes to rob the younger of privileges or to
eliminate the child altogether. And yet each realizes that the rival children are equally
loved by their parents and that therefore one cannot destroy one’s siblings without
incurring parental wrath and thus destroying oneself.
There is only possible solution: equality. If one cannot be the favorite, then there must
be no favorite at all. Everyone is granted an equal investment in the leader, and out of this
demand for equality is born what we have come to know as group spirit. Freud is careful
to remind us that the demand for equality applies only to the other members. They do not
wish to be equal to the leader. Quite the contrary: they have a thirst for obedience—a “lust
for submission,” as Erich Fromm put it.19 I shall return to this shortly. We have regrettably
often witnessed the marriage of weak, devitalized, and demoralized followers to
charismatic, often malignantly narcissistic group leaders.20
Freud was very sensitive to the powerful and irrational manner in which group members
view their leader, and he systematically analyzed this phenomenon and applied it to
psychotherapy.21 Obviously, however, the psychology of member and leader has existed
since the earliest human groupings, and Freud was not the first to note it.† To cite only one
example, Tolstoy in the nineteenth century was keenly aware of the subtle intricacies of
the member-leader relationship in the two most important groups of his day: the church
and the military. His insight into the overvaluation of the leader gives War and Peace
much of its pathos and richness. Consider Rostov’s regard for the Tsar:
He was entirely absorbed in the feeling of happiness at the Tsar’s being near. His
nearness alone made up to him by itself, he felt, for the loss of the whole day. He
was happy, as a lover is happy when the moment of the longed-for meeting has
come. Not daring to look around from the front line, by an ecstatic instance
without looking around, he felt his approach. And he felt it not only from the
sound of the tramping hoofs of the approaching cavalcade, he felt it because as the
Tsar came nearer everything grew brighter, more joyful and significant, and more
festive. Nearer and nearer moved this sun, as he seemed to Rostov, shedding
around him rays of mild and majestic light, and now he felt himself enfolded in

that radiance, he heard his voice—that voice caressing, calm, majestic, and yet so
simple. And Rostov got up and went out to wander about among the campfires,
dreaming of what happiness it would be to die—not saving the Emperor’s life (of
that he did not dare to dream), but simply to die before the Emperor’s eyes. He
really was in love with the Tsar and the glory of the Russian arms and the hope of
coming victory. And he was not the only man who felt thus in those memorable
days that preceded the battle of Austerlitz: nine-tenths of the men in the Russian
army were at that moment in love, though less ecstatically, with their Tsar and the
glory of the Russian arms.22
Indeed, it would seem that submersion in the love of a leader is a prerequisite for war.
How ironic that more killing has probably been done under the aegis of love than of
hatred!
Napoleon, that consummate leader of men, was, according to Tolstoy, not ignorant of
transference, nor did he hesitate to utilize it in the service of victory. In War and Peace,
Tolstoy had him deliver this dispatch to his troops on the eve of battle:
Soldiers! I will myself lead your battalions. I will keep out of fire, if you, with your
habitual bravery, carry defeat and disorder into the ranks of the enemy. But if
victory is for one moment doubtful, you will see your Emperor exposed to the
enemy’s hottest attack, for there can be no uncertainty of victory, especially on this
day, when it is a question of the honor of the French infantry, on which rests the
honor of our nation.23
As a result of transference, the therapy group may impute superhuman powers to the
leaders. Therapists’ words are given more weight and wisdom than they carry. Equally
astute contributions made by other members are ignored or distorted. All progress in the
group is attributed to you, the therapist. Your errors, faux pas, and absences are seen as
deliberate techniques that you employ to stimulate or provoke the group for its own good.
Groups, including groups of professional therapists, overestimate your power and
knowledge. They believe that there are great calculated depths to each of your
interventions, that you predict and control all the events of the group. Even when you
confess puzzlement or ignorance, this, too, is regarded as part of your clever technique,
intended to have a particular effect on the group.
Ah, to be the favorite child—of the parent, of the leader! For many group members, this
longing serves as an internal horizon against which all other group events are silhouetted.
However much each member cares for the other members of the group, however much
each is pleased to see others work and receive help, there is a background of envy, of
disappointment, that one is not basking alone in the light of the leader. The leader’s
inquiries into these domains—who gets the most attention? Who gets the least? Who
seems most favored by the leader?—almost invariably plunge the members into a
profitable examination of the group’s innards.
This desire for sole possession of the leader and the ensuing envy and greed lie deeply
embedded in the substructure of every group. An old colloquialism for the genital organs

is “privates.” However, today many therapy groups discuss sexuality with ease, even
relish. The “privates” of a group are more likely to be the fee structure: money often acts
as the electrodes upon which condense much of the feeling toward the leader. The fee
structure is an especially charged issue in many mental health clinics, which bill members
according to a sliding fee scale based on income. How much one pays is often one of the
group’s most tightly clutched secrets, since differing fees (and the silent, insidious
corollary: different rights, different degrees of ownership) threaten the very cement of the
group: equality for all members. Therapists often feel awkward talking about money:
Group discussion of money and fees may open difficult issues for the therapist such as
income, perceived greed, or entitlement.†
Members often expect the leader to sense their needs. One member wrote a list of major
issues that troubled him and brought it to meeting after meeting, waiting for the therapist
to divine its existence and ask him to read it. Obviously, the content of the list meant little
—if he had really wanted to work on the problems enumerated there, he could have
presented the list to the group himself. No, what was important was the belief in the
therapist’s prescience and presence. This member’s transference was such that he had
incompletely differentiated himself from the therapist. Their ego boundaries were blurred;
to know or feel something was, for him, tantamount to the therapist’s knowing and feeling
it. Many clients carry their therapist around with them. The therapist is in them, observes
their actions from over their shoulder, participates in imaginary conversations with them.
When several members of a group share this desire for an all-knowing, all-caring
leader, the meetings take on a characteristic flavor. The group seems helpless and
dependent. The members deskill themselves and seem unable to help themselves or others.
Deskilling is particularly dramatic in a group composed of professional therapists who
suddenly seem unable to ask even the simplest questions of one another. For example, in
one meeting a group may talk about loss. One member mentions, for the first time, the
recent death of her mother. Then silence. There is sudden group aphasia. No one is even
able to say, “Tell us more about it.” They are all waiting—waiting for the touch of the
therapist. No one wants to encourage anyone else to talk for fear of lessening his or her
chance of obtaining the leader’s ministrations.
Then, at other times or in other groups, the opposite occurs. Members challenge the
leader continuously. The therapist is distrusted, misunderstood, treated like an enemy.
Examples of such negative transference are common. One client, just beginning the group,
expended considerable energy in an effort to dominate the other members. Whenever the
therapist attempted to point this out, the client regarded his intentions as malicious: the
therapist was interfering with his growth; the therapist was threatened by him and was
attempting to keep him subservient; or, finally, the therapist was deliberately blocking his
progress lest he improve too quickly and thus diminish the therapist’s income. Both of
these polarized positions—slavish idealization and unrelenting devaluation, reflect
destructive group norms and represent an antigroup position that demands the therapist’s
attention.24
In a group of adult female incest survivors, I, the only male in the group, was

continually challenged. Unlike my female co-therapist, I could do no right. My appearance
was attacked—my choice of neckties, my wearing socks that were not perfectly matched.
Virtually every one of my interventions was met with criticism. My silence was labeled
disinterest, and my support was viewed with suspicion. When I did not inquire deeply
enough into the nature of their abuse, I was accused of lacking interest and empathy.
When I did inquire, I was accused of being a “closet pervert” who got sexual kicks from
listening to stories of sexual violation. Though I had known that transferential anger from
a group of female abuse victims would be inevitable and useful to the therapy process, and
that the attacks were against my role rather than against my person—still, the attacks were
difficult to tolerate. I began to dread each meeting and felt anxious, deskilled, and
incompetent. The transference was not just being felt or spoken, it was being enacted
powerfully.25 Not only was I attacked as a representative of the prototypical male in these
group members’ lives, but I was also being “abused” in a form of role inversion. This
offered a useful window into the experience of the group members who all too often felt
dread, bullied, and lacking in skill. Understanding the nature of transference and not
retaliating with countertransference rage was essential in retaining a therapeutic posture.
In another group a paranoid client, who had a long history of broken leases and lawsuits
brought against her by landlords, re-created her litigiousness in the group. She refused to
pay her small clinic bill, claiming that there was an error in the account, but she could not
find the time to come to talk to the clinic administrator. When the therapist reminded her
on a number of occasions of the account, she compared him to a Jewish slumlord or a
greedy capitalist who would have liked her to damage her health permanently by slaving
in an environmentally toxic factory.
Another member habitually became physically ill with flu symptoms whenever she
grew depressed. The therapist could find no way to work with her without her feeling he
was accusing her of malingering—a replay of the accusatory process in her relationships
in her family. When one therapist, on a couple of occasions, accepted a Life Saver from a
female member, another member responded strongly and accused him both of mooching
and of exploiting the women in the group.
Many irrational reasons exist for these attacks on the therapist, but some stem from the
same feelings of helpless dependency that result in the worshipful obedience I have
described. Some clients (“counterdependents”) respond counterphobically to their
dependency by incessantly defying the leader. Others validate their integrity or potency by
attempting to triumph over the big adversary, feeling a sense of exhilaration and power
from twisting the tail of the tiger and emerging unscathed.
The most common charge members level against the leader is that of being too cold, too
aloof, too inhuman. This charge has some basis in reality. For both professional and
personal reasons, as I shall discuss shortly, many therapists do keep themselves hidden
from the group. Also, their role of process commentator requires a certain distance from
the group. But there is more to it. Although the members insist that they wish therapists to
be more human, they have the simultaneous counterwish that they be more than human.
(See my novel The Schopenhauer Cure [pp. 221–253] for a fictional portrayal of this

phenomenon.)
Freud often made this observation. In The Future of an Illusion, he based his
explanation for religious belief on the human being’s thirst for a superbeing.26 It seemed
to Freud that the integrity of the group depended on the existence of some superordinate
figure who, as I discussed earlier, fosters the illusion of loving each member equally. Solid
group bonds become chains of sand if the leader is lost. If the general perishes in battle, it
is imperative that the news be kept secret, or panic might break out. So, too, for the leader
of the church. Freud was fascinated by a 1903 novel called When It Was Dark, in which
Christ’s divinity was questioned and ultimately disproved.27 The novel depicted
catastrophic effects on Western European civilization; previously stable social institutions
deconstituted one by one, leaving only social chaos and ideological rubble.
Hence, there is great ambivalence in the members’ directive to the leader to be “more
human.” They complain that you tell them nothing of yourself, yet they rarely inquire
explicitly. They demand that you be more human yet excoriate you if you wear a copper
bracelet, accept a Life Saver, or forget to tell the group that you have conversed with a
member over the phone. They prefer not to believe you if you profess puzzlement or
ignorance. The illness or infirmity of a therapist always arouses considerable discomfort
among the members, as though somehow the therapist should be beyond biological
limitation. The followers of a leader who abandons his or her role are greatly distressed.
(When Shakespeare’s Richard II laments his hollow crown and gives vent to his
discouragement and need for friends, his court bids him to be silent.)
A group of psychiatry residents I once led put the dilemma very clearly. They often
discussed the “big people” out in the world: their therapists, group leaders, supervisors,
and the adult community of senior practicing psychiatrists. The closer these residents
came to completing their training, the more important and problematic the big people
became. I wondered aloud whether they, too, might soon become “big people.” Could it be
that even I had my “big people”?
There were two opposing sets of concerns about the “big people,” and they were
equally troubling: first, that the “big people” were real, that they possessed superior
wisdom and knowledge and would dispense an honest but terrible justice to the young,
presumptuous frauds who tried to join their ranks; or, second, that the “big people”
themselves were frauds, and the members were all Dorothys facing the Oz wizard. The
second possibility had more frightening implications than the first: it brought them face-
to-face with their intrinsic loneliness and apartness. It was as if, for a brief time, life’s
illusions were stripped away, exposing the naked scaffolding of existence—a terrifying
sight, one that we conceal from ourselves with the heaviest of curtains. The “big people”
are one of our most effective curtains. As frightening as their judgment may be, it is far
less terrible than that other alternative—that there are no “big people” and that one is
finally and utterly alone.
The leader is thus seen unrealistically by members for many reasons. True transference
or displacement of affect from some prior object is one reason; conflicted attitudes toward
authority (dependency, distrust, rebellion, counterdependency) that become personified in

the therapist is another; and still another reason is the tendency to imbue therapists with
superhuman features so as to use them as a shield against existential anxiety.
An additional but entirely rational source of members’ strong feelings toward the group
therapist lies in the members’ explicit or intuitive appreciation of the therapist’s great and
real power. Group leaders’ presence and impartiality are, as I have already discussed,
essential for group survival and stability; they have the power to expel members, add new
members, and mobilize group pressure against anyone they wish.
In fact, the sources of intense, irrational feelings toward the therapist are so varied and
so powerful that transference will always occur. The therapist need not make any effort—
for example, striking a pose of unflinching neutrality and anonymity—to generate or
facilitate the development of transference. An illustrative example of transference
developing in the presence of therapist transparency occurred with a client who often
attacked me for aloofness, deviousness, and hiddenness. He accused me of manipulation,
of pulling strings to guide each member’s behavior, of not being clear and open, of never
really coming out and telling the group exactly what I was trying to do in therapy. Yet this
man was a member of a group in which I had been writing very clear, honest, transparent
group summaries and mailing them to the members before the next meeting (see chapter
14). A more earnest attempt to demystify the therapeutic process would be difficult to
imagine. When asked by some of the members about my self-disclosure in the summaries,
he acknowledged that he had not read them—they remained unopened on his desk.
As long as a group therapist assumes the responsibility of leadership, transference will
occur. I have never seen a group develop without a deep, complex underpinning of
transference. The problem is thus not evocation but resolution of transference. The
therapist who is to make therapeutic use of transference must help clients recognize,
understand, and change their distorted attitudinal set toward the leader.
How does the group resolve transference distortions? Two major approaches are seen in
therapy groups: consensual validation and increased therapist transparency.
Consensual Validation
The therapist may encourage a client to validate his or her impressions of the therapist
against those of the other members. If many or all of the group members concur in the
client’s view of and feelings toward the therapist, then it is clear that either the members’
reaction stems from global group forces related to the therapist’s role in the group or that
the reaction is not unrealistic at all—the group members are perceiving the therapist
accurately. If, on the other hand, there is no consensus, if one member alone has a
particular view of the therapist, then this member may be helped to examine the possibility
that he or she sees the therapist, and perhaps other people too, through an internal
distorting prism. In this process the therapist must take care to operate with a spirit of open
inquiry, lest it turn into a process of majority rule. There can be some truth even in the
idiosyncratic reaction of a single member.

Increased Therapist Transparency
The other major approach relies on the therapeutic use of the self. Therapists help clients
confirm or disconfirm their impressions of the therapists by gradually revealing more of
themselves. The client is pressed to deal with the therapist as a real person in the here-and-
now. Thus you respond to the client, you share your feelings, you acknowledge or refute
motives or feelings attributed to you, you look at your own blind spots, you demonstrate
respect for the feedback the members offer you. In the face of this mounting real-life data,
clients are impelled to examine the nature and the basis of their powerful fictitious beliefs
about the therapist.
We use our transparency and self-disclosure to maintain a therapeutic position with our
clients that balances us in a position midway between the client’s transference and its
therapeutic disconfirmation.† Your disclosure about the client’s impact on you is a
particularly effective intervention because it deepens understanding for the mutual impact
between therapist and group member.28
The group therapist undergoes a gradual metamorphosis during the life of the group. In
the beginning you busy yourself with the many functions necessary in the creation of the
group, with the development of a social system in which the many therapeutic factors may
operate, and with the activation and illumination of the here-and-now. Gradually, as the
group progresses, you begin to interact more personally with each of the members, and as
you become more of a fleshed-out person, the members find it more difficult to maintain
the early stereotypes they had projected onto you.
This process between you and each of the members is not qualitatively different from
the interpersonal learning taking place among the members. After all, you have no
monopoly on authority, dominance, sagacity, or aloofness, and many of the members work
out their conflicts in these areas not with the therapist (or not only with the therapist) but
with other members who happen to have these attributes.
This change in the degree of transparency of the therapist is by no means limited to
group therapy. Someone once said that when the analyst tells the analysand a joke, you
can be sure the analysis is approaching its end. However, the pace, the degree, the nature
of the therapist transparency and the relationship between this activity of the therapist and
the therapist’s other tasks in the group are problematic and deserve careful consideration.
More than any other single characteristic, the nature and the degree of therapist self-
disclosure differentiate the various schools of group therapy. Judicious therapist self-
disclosure is a defining characteristic of the interpersonal model of group psychotherapy.29
THE PSYCHOTHERAPIST AND TRANSPARENCY
Psychotherapeutic innovations appear and vanish with bewildering rapidity. Only a truly

intrepid observer would attempt to differentiate evanescent from potentially important and
durable trends in the diffuse, heterodox American psychotherapeutic scene. Nevertheless,
there is evidence, in widely varying settings, of a shift in the therapist’s basic self-
presentation. Consider the following vignettes.
• Therapists leading therapy groups that are observed through a one-way mirror
reverse roles at the end of the meeting. The clients are permitted to observe while
the therapist and the students discuss or rehash the meeting. Or, in inpatient
groups, the observers enter the room twenty minutes before the end of the session
to discuss their observations of the meeting. In the final ten minutes, the group
members react to the observers’ comments.30
• At a university training center, a tutorial technique has been employed in which
four psychiatric residents meet regularly with an experienced clinician who
conducts an interview in front of a one-way mirror. The client is often invited to
observe the postinterview discussion.
• Tom, one of two group co-therapists, began a meeting by asking a client who had
been extremely distressed at the previous meeting how he was feeling and whether
that session had been helpful to him. The co-therapist then said to him, “Tom, I
think you’re doing just what I was doing a couple of weeks ago—pressing the
clients to tell me how effective our therapy is. We both seem on a constant lookout
for reassurance. I think we are reflecting some of the general discouragement in
the group. I wonder whether the members may be feeling pressure that they have to
improve to keep up our spirits.”
• In several groups at an outpatient clinic, the therapists write a thorough
summary (see chapter 14) after each meeting and mail it to the members before the
next session. The summary contains not only a narrative account of the meeting, a
running commentary on process, and each member’s contribution to the session
but also much therapist disclosure: the therapist’s ideas about what was happening
to everyone in the group that meeting; a relevant exposition of the theory of group
therapy; exactly what the therapist was attempting to do in the meeting; the
therapist’s feelings of puzzlement or ignorance about events in the group; and the
therapist’s personal feelings during the session, including both those said and
those unsaid at the time. These summaries are virtually indistinguishable from
summaries the therapists had previously written for their own private records.
Without discussing the merits or the disadvantages of the approaches demonstrated in
these vignettes, it can be said for now that there is no evidence that these approaches
corroded the therapeutic relationship or situation. On the psychiatric ward, in the tutorial,
and in therapy groups, the group members did not lose faith in their all-too-human
therapists but developed more faith in a process in which the therapists were willing to
immerse themselves. The clients who observed their therapists in disagreement learned
that although no one true way exists, the therapists are nonetheless dedicated and
committed to finding ways of helping their clients.
In each of the vignettes, the therapists abandon their traditional role and share some of

their many uncertainties with their clients. Gradually the therapeutic process is
demystified and the therapist in a sense defrocked. The past four decades have witnessed
the demise of the concept of psychotherapy as an exclusive domain of psychiatry.
Formerly, therapy was indeed a closed-shop affair: psychologists were under surveillance
of psychiatrists lest they be tempted to practice psychotherapy rather than counseling;
social workers could do casework but not psychotherapy. Eventually these three
professions—psychiatry, psychology, and social work—joined in their resistance to the
emergence of new psychotherapy professions: the master’s-level psychologists, the
marriage and family counselors, psychiatric nurse practitioners, pastoral counselors, body
workers, movement and dance therapists, art therapists. The “eggshell” era of therapy—in
which the client was considered so fragile and the mysteries of technique so deep that only
the individual with the ultimate diploma dared treat one—is gone forever.†
Nor is this reevaluation of the therapist’s role and authority solely a modern
phenomenon. There were adumbrations of such experimentation among the earliest
dynamic therapists. For example, Sandor Ferenczi, a close associate of Freud who was
dissatisfied with the therapeutic results of psychoanalysis, continually challenged the
aloof, omniscient role of the classical psychoanalyst. Ferenczi and Freud in fact parted
ways because of Ferenczi’s conviction that it was the mutual, honest, and transparent
relationship that therapist and client created together, not the rational interpretation, that
was the mutative force of therapy.31
In his pioneering emphasis on the interpersonal relationship, Ferenczi influenced
American psychotherapy through his impact on future leaders in the field such as William
Alanson White, Harry Stack Sullivan, and Frieda Fromm-Reichman. Ferenczi also had a
significant but overlooked role in the development of group therapy, underscoring the
relational base of virtually all the group therapeutic factors.32 During his last several years,
he openly acknowledged his fallibility to clients and, in response to a just criticism, felt
free to say, “I think you may have touched upon an area in which I am not entirely free
myself. Perhaps you can help me see what’s wrong with me.”33 Foulkes, a British pioneer
group therapist, stated sixty years ago that the mature group therapist was truly modest—
one who could sincerely say to a group, “Here we are together facing reality and the basic
problems of human existence. I am one of you, not more and not less.”34
I explore therapist transparency more fully in other literary forms: two books of stories
based on my psychotherapy cases—Love’s Executioner and Momma and the Meaning of
Life—and in novels—When Nietzsche Wept (in which the client and therapist alternate
roles), and Lying on the Couch in which the therapist protagonist reruns Ferenczi’s mutual
analysis experiment by revealing himself fully to a client.35 After the publication of each
of these books, I received a deluge of letters, from both clients and therapists, attesting to
the widespread interest and craving for a more human relationship in the therapy venture.
My most recent novel, (The Schopenhauer Cure)36 is set in a therapy group in which the
therapist engages in heroic transparency.
Those therapist who attempt greater transparency argue that therapy is a rational,
explicable process. They espouse a humanistic attitude to therapy, in which the client is

considered a full collaborator in the therapeutic venture. No mystery need surround the
therapist or the therapeutic procedure; aside from the ameliorative effects stemming from
expectations of help from a magical being, there is little to be lost and probably much to
be gained through the demystification of therapy. A therapy based on a true alliance
between therapist and enlightened client reflects a greater respect for the capacities of the
client and, with it, a greater reliance on self-awareness rather than on the easier but
precarious comfort of self-deception.
Greater therapist transparency is, in part, a reaction to the old authoritarian medical
healer, who, for many centuries, has colluded with the distressed human being’s wish for
succor from a superior being. Healers have harnessed and indeed cultivated this need as a
powerful agent of treatment. In countless ways, they have encouraged and fostered a belief
in their omniscience: Latin prescriptions, specialized language, secret institutes with
lengthy and severe apprenticeships, imposing offices, and power displays of diplomas—
all have contributed to the image of the healer as a powerful, mysterious, and prescient
figure.
In unlocking the shackles of this ancestral role, the overly disclosing therapist of today
has at times sacrificed effectiveness on the altar of self-disclosure. However, the dangers
of indiscriminate therapist transparency (which I shall consider shortly) should not deter
us from exploring the judicious use of therapist self-disclosure.
The Effect of Therapist Transparency on the Therapy Group
The primary sweeping objection to therapist transparency emanates from the traditional
analytic belief that the paramount therapeutic factor is the resolution of client-therapist
transference. This view holds that the therapist must remain relatively anonymous or
opaque to foster the development of unrealistic feelings toward him or her. It is my
position, however, that other therapeutic factors are of equal or greater importance, and
that the therapist who judiciously uses his or her own person increases the therapeutic
power of the group by encouraging the development of these factors. In doing so, you gain
considerable role flexibility and maneuverability and may, without concerning yourself
about spoiling your role, directly attend to group maintenance, to the shaping of the group
norms (there is considerable research evidence that therapist self-disclosure facilitates
greater openness between group members37 as well as between family members in family
therapy38), and to here-and-now activation and process illumination. By decentralizing
your position in the group, you hasten the development of group autonomy and
cohesiveness. We see corroborating evidence from individual therapy: therapist self-
disclosure is often experienced by clients as supportive and normalizing. It fosters deeper
exploration on the client’s part.† Therapist self-disclosure is particularly effective when it
serves to engage the client authentically and does not serve to control or direct the
therapeutic relationship.†39
A leader’s personal disclosure may have a powerful and indelible effect. In a recent
publication, a member of a group led by Hugh Mullan, a well-known group therapist,

recounts a group episode that occurred forty-five years earlier. The leader was sitting with
his eyes closed in a meeting, and a member addressed him: “You look very comfortable,
Hugh, why’s that?” Hugh responded immediately, “Because I’m sitting next to a woman.”
The member never forgot that odd response. It was enormously liberating and freed him to
experience and express intensely personal material. As he put it, he no longer felt alone in
his “weirdness.”40
One objection to self-disclosure, a groundless objection, I believe, is the fear of
escalation—the fear that once you as therapist reveal yourself, the group will insatiably
demand even more. Recall that powerful forces in the group oppose this trend. The
members are extraordinarily curious about you, yet at the same time wish you to remain
unknown and powerful. Some of these points were apparent in a meeting many years ago
when I had just begun to lead therapy groups. I had just returned from leading a weeklong
residential human relations laboratory (intensive T-group; see chapter 16). Since greater
leader transparency is the rule in such groups, I returned to my therapy group primed for
greater self-revelation.
• Four members, Don, Russell, Janice, and Martha, were present at the twenty-
ninth meeting of the group. One member and my co-therapist were absent; one
other member, Peter, had dropped out of the group at the previous meeting. The
first theme that emerged was the group’s response to Peter’s termination. The
group discussed this gingerly, from a great distance, and I commented that we had,
it seemed to me, never honestly discussed our feelings about Peter when he was
present, and that we were avoiding them now, even after his departure. Among the
responses was Martha’s comment that she was glad he had left, that she had felt
they couldn’t reach him, and that she didn’t feel it was worth it to try. She then
commented on his lack of education and noted her surprise that he had even been
included in the group—an oblique swipe at the therapists.
I felt the group had not only avoided discussing Peter but had also declined to
confront Martha’s judgmentalism and incessant criticism of others. I thought I
might help Martha and the group explore this issue by asking her to go around the
group and describe those aspects of each person she found herself unable to
accept. This task proved very difficult for her, and she generally avoided it by
phrasing her objections in the past tense, as in, “I once disliked some trait in you
but now it’s different.” When she had finished with each of the members, I pointed
out that she had left me out; indeed, she had never expressed her feelings toward
me except through indirect attacks. She proceeded to compare me unfavorably with
the co-therapist, stating that she found me too retiring and ineffectual; she then
immediately attempted to undo the remarks by commenting that “Still waters run
deep” and recalling examples of my sensitivity to her.
The other members suddenly volunteered to tackle the same task and, in the
process, revealed many long-term group secrets: Don’s effeminacy, Janice’s
slovenliness and desexualized grooming, and Russell’s lack of empathy with the
women in the group. Martha was compared to a golf ball: “tightly wound up with

an enamel cover.” I was attacked by Don for my deviousness and lack of interest in
him.
The members then asked me to go around the group in the same manner as they
had done. Being fresh from a seven-day T-group and no admirer of generals who
led their army from the rear, I took a deep breath and agreed. I told Martha that
her quickness to judge and condemn others made me reluctant to show myself to
her, lest I, too, be judged and found wanting. I agreed with the golf ball metaphor
and added that her judgmentalism made it difficult for me to approach her, save as
an expert technician. I told Don that I felt his gaze on me constantly; I knew he
desperately wanted something from me, and that the intensity of his need and my
inability to satisfy that need often made me very uncomfortable. I told Janice that I
missed a spirit of opposition in her; she tended to accept and exalt everything that
I said so uncritically that it became difficult at times to relate to her as an
autonomous adult.
The meeting continued at an intense, involved level, and at its end the observers
expressed grave concerns about my behavior. They felt that I had irrevocably
relinquished my leadership role and become a group member, that the group would
never be the same, and that, furthermore, I was placing my co-therapist, who
would return the following week, in an untenable position.
In fact, none of these predictions materialized. In subsequent meetings, the
group plunged more deeply into work; several weeks were required to assimilate
the material generated in that single meeting. In addition, the group members,
following the model of the therapist, related to one another far more forthrightly
than before and made no demands on me or my co-therapist for escalated self-
disclosure.
There are many different types of therapist transparency, depending on the therapist’s
personal style and the goals in the group at a particular time. Therapists may self-disclose
to facilitate transference resolution; or to model therapeutic norms; or to assist the
interpersonal learning of the members who wanted to work on their relationship with the
group leader; or to support and accept members by saying, in effect, “I value and respect
you and demonstrate this by giving of myself”?
• An illustrative example of therapist disclosure that facilitated therapy occurred in
a meeting when all three women members discussed their strong sexual attraction
to me. Much work was done on the transference aspects of the situation, on the
women being attracted to a man who was obviously professionally off-limits and
unattainable, older, in a position of authority, and so on. I then pointed out that
there was another side to it. None of the women had expressed similar feelings
toward my co-therapist (also male); furthermore, other female clients who had
been in the group previously had had the same feelings. I could not deny that it
gave me pleasure to hear these sentiments expressed, and I asked them to help me
look at my blind spots: What was I doing unwittingly to encourage their positive
response?

My request opened up a long and fruitful discussion of the group members’
feelings about both therapists. There was much agreement that the two of us were
very different: I was more vain, took much more care about my physical
appearance and clothes, and had an exactitude and preciseness about my
statements that created about me an attractive aura of suaveness and confidence.
The other therapist was sloppier in appearance and behavior: he spoke more often
when he was unsure of what he was going to say; he took more risks, was willing
to be wrong, and, in so doing, was more often helpful to the clients. The feedback
sounded right to me. I had heard it before and told the group so. I thought about
their comments during the week and, at the following meeting, thanked the group
and told them that they had been helpful to me.
Making errors is commonplace: it is what is done with the error that is often critical in
therapy. Therapists are not omniscient, and it is best to acknowledge that.
• After an angry exchange between two members, Barbara and Susan, the group
found it difficult to repair the damage experienced by Barbara. Although Barbara
was eventually able to work through her differences with Susan, she continued to
struggle with how she had been left so unprotected by the group therapist.
Numerous attempts at explanation and understanding failed to break the impasse,
until I stated: “I regret what happened very much. I have to acknowledge that
Susan’s criticism of you took me by surprise—it hit like a tropical storm, and I was
at a loss for words. It took me some time to regroup, but by then the damage had
been done. If I knew then what I know now, I would have responded differently. I
am sorry for that.”
Rather than feeling that I was not competent because I had missed something of
great importance, Barbara felt relieved and said that was exactly what she needed
to hear. Barbara did not need me to be omnipotent—she wanted me to be human,
to be able to acknowledge my error, and to learn from what happened so that it
would be less likely to occur in the future.

• Another illustrative clinical example occurred in the group of women incest
survivors that I mentioned earlier in this chapter. The withering anger toward me
(and, to a slightly lesser degree, toward my female co-therapist) had gotten to us,
and toward the end of one meeting, we both openly discussed our experience in the
group. I revealed that I felt demoralized and deskilled, that everything I tried in the
group had failed to be helpful, and furthermore that I felt anxious and confused in
the group. My co-leader discussed similar feelings: her discomfort about the
competitive way the women related to her and about the continual pressure placed
on her to reveal any abuse that she may have experienced. We told them that their
relentless anger and distrust of us was fully understandable in the light of their
past abuse but, nonetheless, we both wanted to shriek, “These were terrible things
that happened to you, but we didn’t do them.”
This episode proved to be a turning point for the group. There was still one

member (who reported having undergone savage ritual abuse as a child) who
continued in the same vein (“Oh, you’re uncomfortable and confused! What a
shame! What a shame! But at least now you know how it feels”). But the others
were deeply affected by our admission. They were astounded to learn of our
discomfort and of their power over us, and gratified that we were willing to
relinquish authority and to relate to them in an open, egalitarian fashion. From
that point on, the group moved into a far more profitable work phase.
In addition, the “now you know how it feels” comment illuminated one of the
hidden reasons for the attacks on the therapist. It was an instance of the group
member both demonstrating and mastering her experience of mistreatment by
being the aggressor rather than the mistreated.
It was constructive for the therapists to acknowledge and work with these feelings
openly rather than simply continue experiencing them.41 Being so intensely devalued is
unsettling to almost all therapists, especially in the public domain of the group. Yet it also
creates a remarkable therapeutic opportunity if therapists can maintain their dignity and
honestly address their experience in the group.†

These clinical episodes illustrate some general principles that prove useful to the
therapist when receiving feedback, especially negative feedback:
1. Take it seriously. Listen to it, consider it, and respond to it. Respect the clients and
let their feedback matter to you; if you don’t, you merely increase their sense of
impotence.
2. Obtain consensual validation: Find out how other members feel. Determine
whether the feedback is primarily a transference reaction or is in fact a piece of
reality about you. If it is reality, you must confirm it; otherwise, you impair rather
than facilitate your clients’ reality testing.
3. Check your internal experience: Does the feedback fit? Does it click with your
internal experience?
With these principles as guidelines, the therapist may offer such responses as: “You’re
right. There are times when I feel irritated with you, but at no time do I feel I want to
impede your growth, seduce you, get a voyeuristic pleasure from listening to your account
of your abuse, or slow your therapy so as to earn more money from you. That simply isn’t
part of my experience of you.” Or: “It’s true that I dodge some of your questions. But
often I find them unanswerable. You imbue me with too much wisdom. I feel
uncomfortable by your deference to me. I always feel that you’ve put yourself down very
low, and that you’re always looking up at me.” Or: “I’ve never heard you challenge me so
directly before. Even though it’s a bit scary for me, it’s also very refreshing.” Or: “I feel
restrained, very unfree with you, because you give me so much power over you. I feel I
have to check every word I say because you give so much weight to all of my statements.”
Note that these therapist disclosures are all part of the here-and-now of the group. I am

advocating that therapists relate authentically to clients in the here-and-now of the therapy
hour, not that they reveal their past and present in a detailed manner—although I have
never seen harm in therapists’ answering such broad personal questions as whether they
are married or have children, where they are going on vacation, where they were brought
up, and so on. Some therapists carry it much further and may wish to describe some
similar personal problems they encountered and overcame. I personally have rarely found
this useful or necessary.42p
A study of the effects of therapist disclosure on a group over a sevenmonth period noted
many beneficial effects from therapist transparency.43 First, therapist disclosure was more
likely to occur when therapeutic communication among members was not taking place.
Second, the effect of therapist disclosure was to shift the pattern of group interaction into a
more constructive, sensitive direction. Finally, therapist self-disclosure resulted in an
immediate increase in cohesiveness. Yet many therapists shrink from self-disclosure
without being clear about their reasons for doing so. Too often, perhaps, they rationalize
by cloaking their personal inclinations in professional garb. There is little doubt, I believe,
that the personal qualities of a therapist influence professional style, choice of ideological
school, and preferred clinical models.†
In debriefing sessions after termination I have often discussed therapist disclosure with
clients. The great majority have expressed the wish that the therapist had been more open,
more personally engaged in the group. Very few would have wanted therapists to have
discussed more of their private life or personal problems with them. A study of individual
therapy had the same findings—clients prefer and in fact thrive on therapist engagement
and prefer therapists who are “not too quiet.”44 No one expressed a preference for full
therapist disclosure.
Furthermore, there is evidence that leaders are more transparent than they know. The
issue is not that we reveal ourselves—that is unavoidable45—rather, it is what use we
make of our transparency and our clinical honesty. Some self-revelation is inadvertent or
unavoidable—for example, pregnancy, bereavement, and professional accomplishments.46
In some groups, particularly homogeneous groups with a focus such as substance abuse,
sexual orientation, or specific medical illness (see chapter 15), leaders will likely be asked
about their personal relationship to the common group focus: Have they had personal
experience with substance abuse? Are they gay? Have they personally had the medical
disease that is the focus of the group? Therapists need to reveal the relevant material about
themselves that helps group members realize that the therapist can understand and
empathize with the clients’ experiences. That does not mean, however, that the therapist
must provide extensive personal historical details. Such revelations are usually unhelpful
to the therapy because they blur the difference in role and function between the therapist
and the group members.
Though members rarely press a therapist for inappropriate disclosure, occasionally one
particular personal question arises that group therapists dread. It is illustrated in a dream of
a group member (the same member who likened the therapist to a Jewish slumlord): “The
whole group is sitting around a long table with you (the therapist) at the head. You had in

your hand a slip of paper with something written on it. I tried to snatch it away from you
but you were too far away.” Months later, after this woman had made some significant
personal changes, she recalled the dream and added that she knew all along what I had
written on the paper but hadn’t wanted to say it in front of the group. It was my answer to
the question, “Do you love me?” This is a threatening question for the group therapist.
And there is a related and even more alarming follow-up question: “How much do you
love each of us?” or, “Whom do you love best?”
These questions threaten the very essence of the psychotherapeutic contract. They
challenge tenets that both parties have agreed to keep invisible. They are but a step away
from a commentary on the “purchase of friendship” model: “If you really care for us,
would you see us if we had no money?” They come perilously close to the ultimate,
terrible secret of the psychotherapist, which is that the intense drama in the group room
plays a smaller, compartmentalized role in his or her life. As in Tom Stoppard’s play
Rosencrantz and Guildenstern Are Dead, key figures in one drama rapidly become
shadows in the wings as the therapist moves immediately onto the stage of another drama.
Only once have I been blasphemous enough to lay this bare before a group. A therapy
group of psychiatry residents was dealing with my departure (for a year’s sabbatical
leave). My personal experience during that time was one of saying good-bye to a number
of clients and to several groups, some of which were more emotionally involving for me
than the resident group. Termination work was difficult, and the group members attributed
much of the difficulty to the fact that I had been so involved in the group that I was
finding it hard to say good-bye. I acknowledged my involvement in the group but
presented to them the fact that they knew but refused to know: I was vastly more
important to them than they were to me. After all, I had many clients; they had only one
therapist. They were clearly aware of this imbalance in their psychotherapeutic work with
their own clients, and yet had never applied it to themselves. There was a gasp in the
group as this truth, this denial of specialness, this inherent cruelty of psychotherapy, hit
home.

The issue of therapist transparency is vastly complicated by widely publicized instances
of therapist-client sexual abuse. Unfortunately, the irresponsible or impulse-ridden
therapists who, to satisfy their own needs, betray their professional and moral covenant
have not only damaged their own clients but caused a backlash that has damaged the trust
in the client-therapist relationship everywhere.
Many professional associations have taken a highly reactionary stance toward the
professional relationship. Feeling threatened by legal action, they advise therapists to
practice defensively and always keep potential litigation in mind. The lawyers and juries,
they say, will reason that “where there is smoke, there is fire” and that since every
therapist-client encounter started down the slippery slope of slight boundary crossings,
human interactions between client and therapist are in themselves evidence of
wrongdoing. Consequently, professional organizations warn therapists to veer away from

the very humanness that is the core of the therapeutic relationship. An article with a high
Victorian tone in a 1993 issue of the American Journal of Psychiatry,47 for example,
advocated a stifling formality and warned psychiatrists not to offer their clients coffee or
tea, not to address them by their first names, not to use their own first names, never to run
over the fifty-minute time period, never to see any client during the last working hour of
the day (since that is when transgressions most often occur), never to touch a client—even
an act such as squeezing the arm or patting the back of an AIDS patient who needs
therapeutic touch should be scrutinized and documented.q Obviously, these instructions
and the sentiment behind them are deeply corrosive to the therapeutic relationship. To
their credit, the authors of the 1993 article recognized the antitherapeutic impact of their
first article and wrote a second paper five years later aimed at correcting the overreaction
generated by the first article. The second article makes a plea for common sense and for
recognition of the importance of the clinical context in understanding or judging boundary
issues in therapy. They encourage therapists to obtain consultation or supervision
whenever they are uncertain about their therapeutic posture or interventions.48
But moderation in all things. There is a proper place for therapist concealment, and the
most helpful therapist is by no means the one who is most fully and most consistently self-
disclosing. Let us turn our attention to the perils of transparency.
Pitfalls of Therapist Transparency
Some time ago I observed a group led by two neophyte therapists who were at that time
much dedicated to the ideal of therapist transparency. They formed an outpatient group
and conducted themselves in an unflinchingly honest fashion, expressing openly in the
first meetings their uncertainty about group therapy, their inexperience, their self-doubts,
and their personal anxiety. One might admire their courage, but not their results. In their
overzealous obeisance to transparency, they neglected their function of group
maintenance, and the majority of the members dropped out of the group within the first six
sessions.
Untrained leaders who undertake to lead groups with the monolithic credo “Be
yourself” as a central organizing principle for all other technique and strategy generally
achieve not freedom but restriction. The paradox is that freedom and spontaneity in
extreme form can result in a leadership role as narrow and restrictive as the traditional
blank-screen leader. Under the banner of “Anything goes if it’s genuine,” the leader
sacrifices flexibility.49
Consider the issue of timing. The fully open neophyte therapists I just mentioned
overlooked the fact that leadership behavior that may be appropriate at one stage of
therapy may be quite inappropriate at another. If clients need initial support and structure
to remain in the group, then it is the therapist’s task to provide it.
The leader who strives only to create an atmosphere of egalitarianism between member
and leader may in the long run provide no leadership at all. Effective leader role behavior

is by no means unchanging; as the group develops and matures, different forms of
leadership are required.50 “The honest therapist” as Parloff states, “is one who attempts to
provide that which the client can assimilate, verify and utilize.”51 Ferenczi years ago
underscored the necessity for proper timing. The analyst, he said, must not admit his flaws
and uncertainty too early.52 First, the client must feel sufficiently secure in his own
abilities before being called upon to face defects in the one on whom he leans.r
Research on group members’ attitudes toward therapist self-disclosure shows that
members are sensitive to the timing and the content of disclosure. 53 Therapists’
disclosures that are judged as harmful in early phases of the group are considered
facilitative as a group matures. Furthermore, members who have had much group therapy
experience are far more desirous of therapist self-disclosure than are inexperienced group
members. Content analysis demonstrates that members prefer leaders who disclose
positive ambitions (for example, personal and professional goals) and personal emotions
(loneliness, sadness, anger, worries, and anxieties); they disapprove of a group leader’s
expressing negative feelings about any individual member or about the group experience
(for example, boredom or frustration).54 Not all emotions can be expressed by the
therapist. Expressing hostility is almost invariably damaging and often irreparable,
contributing to premature termination and negative therapy outcomes.†
Is full disclosure even possible in the therapy group or in the outside world? Or
desirable? Some degree of personal and interpersonal concealment are an integral
ingredient of any functioning social order. Eugene O’Neill illustrated this in dramatic form
in the play The Iceman Cometh.55 A group of derelicts live, as they have for twenty years,
in the back room of a bar. The group is exceedingly stable, with many well-entrenched
group norms. Each man maintains himself by a set of illusions (“pipe dreams,” O’Neill
calls them). One of the most deeply entrenched group norms is that no members challenge
another’s pipe dreams. Then enters Hickey, the iceman, a traveling salesman, a totally
enlightened therapist, a false prophet who believes he brings fulfillment and lasting peace
to each man by forcing him to shed his self-deceptions and stare with unblinking honesty
at the sun of his life. Hickey’s surgery is deft. He forces Jimmy Tomorrow (whose pipe
dream is to get his suit out of hock, sober up, and get a job “tomorrow”) to act now. He
gives him clothes and sends him, and then the other men, out of the bar to face today.
The effects on each man and on the group are calamitous. One commits suicide, others
grow severely depressed, “the life goes out of the booze,” the men attack one another’s
illusions, the group bonds disintegrate, and the group veers toward dissolution. In a
sudden, last-minute convulsive act, the group labels Hickey psychotic, banishes him, and
gradually reestablishes its old norms and cohesion. These “pipe dreams”—or “vital lies,”
as Henrik Ibsen called them in The Wild Duck56—are often essential to personal and social
integrity. They should not be taken lightly or impulsively stripped away in the service of
honesty.
Commenting on the social problems of the United States, Victor Frankl once suggested
that the Statue of Liberty on the East Coast be counterbalanced by a Statue of

Responsibility on the West Coast.57 In the therapy group, freedom becomes possible and
constructive only when it is coupled with responsibility. None of us is free from impulses
or feelings that, if expressed, could be destructive to others. I suggest that we encourage
clients and therapists to speak freely, to shed all internal censors and filters save one—the
filter of responsibility to others.
I do not mean that no unpleasant sentiments are to be expressed; indeed, growth cannot
occur in the absence of conflict. I do mean, however, that responsibility, not total
disclosure, is the superordinate principle.† The therapist has a particular type of
responsibility—responsibility to clients and to the task of therapy. Group members have a
human responsibility toward one another. As therapy progresses, as solipsism diminishes,
as empathy increases, they come to exercise that responsibility in their interactions among
themselves.
Thus, your raison d’être as group therapist is not primarily to be honest or fully
disclosing. You must be clear about why you reveal yourself. Do you have a clear
therapeutic intent or is countertransference influencing your approach? What impact can
you anticipate from your self-disclosure? In times of confusion about your behavior, you
may profit from stepping back momentarily to reconsider your primary tasks in the group.
Therapist self-disclosure is an aid to the group because it sets a model for the clients and
permits some members to reality-test their feelings toward you. When considering a self-
disclosure, ask yourself where the group is now. Is it a concealed, overly cautious group
that may profit from a leader who models personal self-disclosure? Or has it already
established vigorous self-disclosure norms and is in need of other kinds of assistance?
Again, you must consider whether your behavior will interfere with your group-
maintenance function. You must know when to recede into the background. Unlike the
individual therapist, the group therapist does not have to be the axle of therapy. In part,
you are midwife to the group: you must set a therapeutic process in motion and take care
not to interfere with that process by insisting on your centrality.
An overly restricted definition of the role of group therapist—whether based on
transparency or any other criterion—may cause the leader to lose sight of the individuality
of each client’s needs. Despite your group orientation, you must retain some individual
focus; not all clients need the same thing. Some, perhaps most, clients need to relax
controls; they need to learn how to express their affect—anger, love, tenderness, hatred.
Others, however, need the opposite: they need to gain impulse control because their
lifestyles are already characterized by labile, immediately acted-upon affect.
One final consequence of more or less unlimited therapist transparency is that the
cognitive aspects of therapy may be completely neglected. As I noted earlier, mere
catharsis is not in itself a corrective experience. Cognitive learning or restructuring (much
of which is provided by the therapist) seems necessary for the client to be able to
generalize group experiences to outside life; without this transfer or carryover, we have
succeeded only in creating better, more gracious therapy group members. Without the
acquisition of some knowledge about general patterns in interpersonal relationships, the
client may, in effect, have to rediscover the wheel in each subsequent interpersonal

transaction.

Chapter 8
THE SELECTION OF CLIENTS
Good group therapy begins with good client selection. Clients improperly assigned to a
therapy group are unlikely to benefit from their therapy experience. Furthermore, an
improperly composed group may end up stillborn, never having developed into a viable
treatment mode for any of its members. It is therefore understandable that contemporary
psychotherapy researchers are actively examining the effects of matching clients to
psychotherapies according to specific characteristics and attributes.1
In this chapter I consider both the research evidence bearing on selection and the
clinical method of determining whether a given individual is a suitable candidate for group
therapy. In chapter 9, on group composition, I will examine a different question: once it
has been decided that a client is a suitable group therapy candidate, into which specific
group should he or she go? These two chapters focus particularly on a specific type of
group therapy: the heterogeneous outpatient group with the ambitious goals of
symptomatic relief and characterological change. However, as I shall discuss shortly,
many of these general principles have relevance to other types of groups, including the
shorter-term problem-oriented group. Here, as elsewhere in this book, I employ the
pedagogic strategy of providing the reader with fundamental group therapy principles plus
strategies for adapting these principles to a variety of clinical situations. † There is no
other reasonable educative strategy. Such a vast number of problem-specific groups exist
(see also chapter 15) that one cannot focus separately on selection strategy for each
specific one—nor would a teacher wish to. That would result in too narrow and too rigid
an education. The graduate of such a curriculum would be unable to adapt to the forms
that group therapy may take in future years. Once students are grounded in the
prototypical psychotherapy group they will have the base which will permit them to
modify technique to fit diverse clinical populations and settings.
Effectiveness of group therapy. Let us begin with the most fundamental question in
client selection: Should the client—indeed, any client—be sent to group therapy? In other
words, how effective is group therapy? This question, often asked by individual therapists
and always asked by third-party payers, must be addressed before considering more subtle
questions of client selection. The answer is unequivocal. Group therapy is a potent
modality producing significant benefit to its participants.2
A great deal of research has also attempted to determine the relative efficacy of group
versus individual therapy, and the results are clear: there is considerable evidence that
group therapy is at least as efficacious as individual therapy. An excellent, early review of
the thirty-two existing well-controlled experimental studies that compared individual and
group therapys indicates that group therapy was more effective than individual therapy in
25 percent of the studies. In the other 75 percent, there were no significant differences
between group and individual therapy.3 In no study was individual therapy more effective.
A more recent review using a rigorous meta-analysist demonstrated similar findings.4

Other reviews, some including a greater number of studies (but less rigorously controlled),
have reached similar conclusions and underscore that group therapy is also more efficient
than individual therapy (from the standpoint of therapist resources) by a factor of two to
one and perhaps as much as four to one.5
Research indicates further that group therapy has specific benefits: It is for example
superior to individual therapy in the provision of social learning, developing social
support, and improving social networks, factors of great importance in reducing relapse
for clients with substance use disorders.6 It is more effective than individual approaches
for obesity7 (an effect achieved in part through reducing stigma), and for clients with
medical illness—clients learn to enhance self-efficacy better from peers than from
individual therapy.8 Adding group therapy to the treatment of women who are survivors of
childhood sexual abuse provides benefits beyond individual therapy: it results in greater
empowerment and psychological well-being.9
The evidence for the effectiveness of group therapy is so persuasive that some experts
advocate that group therapy be utilized as the primary model of contemporary
psychotherapy.10 Individual therapy, however, may be preferable for clients who require
active clinical management, or when relationship issues are less important and personal
insight and understanding are particularly important.11
So far, so good! We can be confident (and each of us should convey this confidence to
sources of referral and to third-party payers) that group therapy is an effective treatment
modality.
One might reasonably expect the research literature to yield useful answers to the
question of which clients do best in group therapy and which are better referred to another
form of therapy. After all, here’s all that needs to be done: Describe and measure a
panoply of clinical and demographic characteristics before clients are randomly assigned
to group therapy or to other modalities and then correlate these characteristics with
appropriate dependent variables, such as therapy outcome, or perhaps some intervening
variable, such as attendance, mode of interaction, or cohesiveness.
But the matter turns out to be far more complex. The methodological problems are
severe, not least because a true measure of psychotherapy outcome is elusive. The client
variables used to predict therapy outcome are affected by a host of other group, leader, and
comember variables that confound the research enterprise.†12 Clients drop out of therapy;
many obtain ancillary individual therapy; group therapists vary in competence and
technique; and initial diagnostic technique is unreliable and often idiosyncratic. An
enormous number of clients are needed to obtain enough therapy groups for the results to
be statistically significant. Although standardized therapies are required to ensure that
each of the treatment modalities is delivering proper therapy, still each person and each
group is exquisitely complex and cannot simplify itself in order to be precisely measured.
Hence in this chapter I draw on relevant research but also rely heavily on clinical
experience—my own and that of others.

CRITERIA FOR EXCLUSION
Question: How do group clinicians select clients for group psychotherapy? Answer: The
great majority of clinicians do not select for group therapy. Instead, they deselect. Given a
pool of clients, experienced group therapists determine that certain ones cannot possibly
work in a therapy group and should be excluded. And then they proceed to accept all the
other clients.
That approach seems crude. We would all prefer the selection process to be more
elegant, more finely tuned. But, in practice, it is far easier to specify exclusion than
inclusion criteria; one characteristic is sufficient to exclude an individual, whereas a more
complex profile must be delineated to justify inclusion.
Keep in mind that there are many group therapies, and exclusion criteria apply only for
the type of group under consideration. Almost all clients (there are exceptions) will fit into
some group. A characteristic that excludes someone from one group may be the exact
feature that secures entry into another group. A secretive, non–psychologically minded
client with anorexia nervosa, for example, is generally a poor candidate for a long-term
interactional group, but may be ideal for a homogeneous, cognitive-behavioral eating-
disorders group.†
There is considerable clinical consensus that clients are poor candidates for a
heterogeneous outpatient therapy group if they are brain-damaged,13 paranoid,14
hypochondriacal,15 addicted to drugs or alcohol,16 acutely psychotic, 17 or sociopathic.†
But such dry lists are of less value than identifying underlying principles. Here is the
major guideline: clients will fail in group therapy if they are unable to participate in the
primary task of the group, be it for logistical, intellectual, psychological, or interpersonal
reasons . This consideration is even more compelling for brief, time-limited groups, which
are particularly unforgiving of poor client selection.†
What traits must a client possess to participate in the primary task of the dynamic,
interactional therapy group? They must have a capacity and willingness to examine their
interpersonal behaviors, to self-disclose, and to give and receive feedback. Unsuitable
clients tend to construct an interpersonal role that proves detrimental to themselves as well
as to the group. In such instances the group becomes a venue for re-creating and
reconfirming maladaptive patterns without the possibility of learning or change.
Consider sociopathic clients, for example, who are exceptionally poor candidates for
outpatient interactional group therapy. Characteristically, these individuals are destructive
in the group. Although early in therapy they may become important and active members,
they will eventually manifest their basic inability to relate, often with considerable
dramatic and destructive impact, as the following clinical example illustrates.
• Felix, a highly intelligent thirty-five-year-old man with a history of alcoholism,
transiency, and impoverished interpersonal relationships, was added with two
other new clients to an ongoing group, which had been reduced to three by the

recent graduation of members. The group had shrunk so much that it seemed in
danger of collapsing, and the therapists were anxious to reestablish its size. They
realized that Felix was not an ideal candidate, but they had few applicants and
decided to take the risk. In addition, they were somewhat intrigued by his stated
determination to change his lifestyle. (Many sociopathic individuals are forever
“reaching a turning point in life.”)
By the third meeting, Felix had become the social and emotional leader of the
group, seemingly able to feel more acutely and suffer more deeply than the other
members. He presented the group, as he had the therapists, with a largely
fabricated account of his background and current life situation. By the fourth
meeting, as the therapists learned later, he had seduced one of the female members
and, in the fifth meeting, he spearheaded a discussion of the group’s dissatisfaction
with the brevity of the meetings. He proposed that the group, with or without the
permission of the therapist, meet more often, perhaps at one of the members’
homes, without the therapist. By the sixth meeting, Felix had vanished, without
notifying the group. The therapists learned later that he had suddenly decided to
take a 2,000-mile bicycle trip, hoping to sell an article about it to a magazine.
This extreme example illustrates many of the reasons why the inclusion of a sociopathic
individual in a heterogeneous ambulatory group is ill advised: his social front is deceptive;
he often consumes such an inordinate amount of group energy that his departure leaves the
group bereft, puzzled, and discouraged; he rarely assimilates the group therapeutic norms
and instead often exploits other members and the group as a whole for his immediate
gratification. Let me emphasize that I do not mean that group therapy per se is
contraindicated for sociopathic clients. In fact, a specialized form of group therapy with a
more homogeneous population and a wise use of strong group and institutional pressure
may well be the treatment of choice.18
Most clinicians agree that clients in the midst of some acute situational crisis are not
good candidates for group therapy; they are far better treated in crisis-intervention therapy
in an individual, family, or social network format.19 Deeply depressed suicidal clients are
best not admitted to an interactionally focused heterogeneous therapy group either. It is
difficult for the group to give them the specialized attention they require (except at
enormous expense of time and energy to the other members); furthermore, the threat of
suicide is too taxing, too anxiety provoking, for the other group members to manage.20
Again, that does not mean that group therapy per se (or group therapy in combination with
individual therapy) should be ruled out. A structured homogeneous group for chronic
suicidality has been reported to be effective.21
Good attendance is so necessary for the development of a cohesive group that it is wise
to exclude clients who, for any reason, may not attend regularly. Poor attendance may be
due to unpredictable and hard-to-control work demands, or it may be an expression of
initial resistance to therapy. I do not select individuals whose work requires extensive
travel that would cause them to miss even one out of every four or five meetings.
Similarly, I am hesitant to select clients who must depend on others for transportation to

the group or who would have a very long commute to the group. Too often, especially
early in the course of a group, a client may feel neglected or dissatisfied with a meeting,
perhaps because another member may have received the bulk of the group time and
attention, or the group may have been busy building its own infrastructure—work that
may not offer obvious immediate gratification. Deep feelings of frustration may, if
coupled with a long, strenuous commute, dampen motivation and result in sporadic
attendance.
Obviously, there are many exceptions: some therapists tell of clients who faithfully fly
to meetings from remote regions month after month. As a general rule, however, the
therapist does well to heed this factor. For clients who live at considerable distance and
have equivalent groups elsewhere, it is in everyone’s interests to refer them to a group
closer to home.
These clinical criteria for exclusion are broad and crude. Some therapists have
attempted to arrive at more refined criteria through systematic study of clients who have
failed to derive benefit from group therapy. Let me examine the research on one category
of unsuccessful clients: the group therapy dropouts.
Dropouts
There is evidence that premature termination from group therapy is bad for the client and
bad for the group. In a study of thirty-five clients who dropped out of long-term
heterogeneous interactional outpatient groups in twelve or fewer meetings, I found that
only three reported themselves as improved.22 Moreover, those three individuals had only
marginal symptomatic improvement. None of the thirty-five clients left therapy because
they had satisfactorily concluded their work; they had all been dissatisfied with the
therapy group experience. Their premature terminations had, in addition, an adverse effect
on the remaining members of the group, who were threatened and demoralized by the
early dropouts. In fact, many group leaders report a “wave effect,” with dropouts begetting
other dropouts. The proper development of a group requires membership stability; a rash
of dropouts may delay the maturation of a group for months.
Early group termination is thus a failure for the individual and a detriment to the
therapy of the remainder of the group. Unfortunately, it is common across the
psychotherapies. A recent empirical analysis concluded that 47 percent of all clients leave
psychotherapy (group and individual therapy as well) prematurely.23 Even in expert hands
some dropouts are unavoidable, no doubt because of the complex interplay of client,
group, and therapist variables.24 Consider the dropout rates displayed in table 8.1: group
therapy attrition ranges from 17 percent to 57 percent. Although this rate is no higher than
the dropout rate from individual therapy, the dropout phenomenon is of more concern to
group therapists because of the deleterious effects of dropouts on the rest of the group.
A study of early dropouts may help establish sound exclusion criteria and, furthermore,
may provide an important goal for the selection process. If, in the selection process, we

learn merely to screen out members destined to drop out of therapy, that in itself would
constitute a major achievement. Although the early terminators are not the only failures in
group therapy, they are unequivocal failures.† We may, I think, dismiss as unlikely the
possibility that early dropouts will have gained something positive that will manifest itself
later. A relevant outcome study of encounter group participants noted that individuals who
had a negative experience in the group did not, when studied six months later, “put it all
together” and enjoy a delayed benefit from the group experience. 25 If they left the group
shaken or discouraged, they were very likely to remain that way. (One exception to the
rule may be individuals who enter in some urgent life crisis and terminate therapy as soon
as the crisis is resolved.)
Keep in mind that the study of group dropouts tells us little about the group continuers;
group continuation is a necessary but insufficient factor in successful therapy, although
evidence exists that clients who continue in treatment and avoid premature or forced
ending achieve the best therapy outcomes.26
Reasons for Premature Termination
A number of rigorous studies of group therapy in various settings (ambulatory, day
hospital, Veterans Administration clinics, and private practice, including both
heterogeneous groups and homogeneous groups for problems such as grief or depression,
and conducted in an interactional manner or along cognitive-behavioral lines) have
convergent findings.27,28 These studies demonstrate that clients who drop out prematurely
from group therapy are likely, at the initial screening or in the first few meetings, to have
one or more of the following characteristics:
• Lower psychological-mindedness
• Reduced capacity to think about emotions without action
• Lower motivation
• More reactive than reflective
• Less positive emotion
• Greater denial
• Higher somatization
• Abuse of substances
• Greater anger and hostility
• Lower socioeconomic class and social effectiveness
• Lower intelligence
• Lack of understanding of how group therapy works
• The experience or expectation of cultural insensitivity

• Less likable (at least according to therapists)
TABLE 8.1 Group Therapy Dropout Rates
These conclusions suggest that, unfortunately, the rich get richer and the poor get
poorer. What a paradox! The clients who have the least skills and attributes needed for
working in a group—the very ones who most need what the group has to offer—are those
most likely to fail! It is this paradox (along with economic issues) that has stimulated
attempts to modify the therapy group experience sufficiently with different structures and
outreach to accommodate more of these at-risk clients.†
Keep in mind that these characteristics should therefore be seen as cautions rather than
absolute contraindications. The person who fails in one group or in one type of group may
do well in a different one. We should aim to reduce, not eliminate dropouts. If we create
groups that never experience a dropout, then it may be that we are setting our bar for entry
too high, thus eliminating clients in need who we may in fact be able to help.
I will discuss one final study here in great detail, since it has considerable relevance for
the selection process.29 I studied the first six months of nine therapy groups in a university
outpatient clinic and investigated all clients who terminated in twelve or fewer meetings.
A total of ninety-seven clients were involved in these groups (seventy-one original

members and twenty-six later additions); of these, thirty-five were early dropouts.
Considerable data were generated from interviews and questionnaire studies of the
dropouts and their therapists as well as from the records and observations of the group
sessions and historical and demographic data from the case records.
An analysis of the data suggested nine major reasons for the clients’ dropping out of
therapy:
1. External factors
2. Group deviancy
3. Problems of intimacy
4. Fear of emotional contagion
5. Inability to share the therapist
6. Complications of concurrent individual and group therapy
7. Early provocateurs
8. Inadequate orientation to therapy
9. Complications arising from subgrouping
Usually more than one factor is involved in the decision to terminate. Some factors are
more closely related to external circumstances or to enduring character traits that the client
brings to the group, and thus are relevant to the selection process, whereas others are
related to the therapist or to problems arising within the group (for example, the therapist’s
skill and competence, client-therapist interaction variables, and the group culture itself)†
and thus are more relevant to therapist technique (I will discuss these issues in chapters 10
and 11). Most relevant to the establishment of selection criteria are the clients who
dropped out because of external factors, group deviancy, and problems of intimacy.

External Factors. Logistical reasons for terminating therapy (for example, irreconcilable
scheduling conflicts, moving out of the geographic area) played a negligible role in
decisions to terminate. When this reason was offered by the client, closer study usually
revealed group-related stress that was more pertinent to the client’s departure.
Nevertheless, in the initial screening session, the therapist should always inquire about any
pending major life changes, such as a move. There is considerable evidence that therapy
aimed at both symptom relief and making major changes in the clients’ underlying
character structure is not a brief form of therapy—a minimum of six months is necessary†
—and that clients should not be accepted into such therapy if there is a considerable
likelihood of forced termination within the next few months. Such individuals are better
candidates for shorter-term, problem-oriented groups.
External stress was considered a factor in the premature dropout of several clients who
were so disturbed by external events in their lives that it was difficult for them to expend
the energy for involvement in the group. They could not explore their relationships with

other group members while they were consumed with the threat of disruption of
relationships with the most significant people in their lives. It seemed especially pointless
and frustrating to them to hear other group members discuss their problems when their
own problems seemed so compelling. Among the external stresses were severe marital
discord with impending divorce, impending career or academic failure, disruptive
relationship with family members, bereavement, and severe physical illness. In such
instances referrals should be made to groups explicitly designed to deal with such
situations: acute grief, for example, is generally a time-limited condition, and the acutely
bereaved client is best referred to a short-term bereavement group.30
Note an important difference! If the goal is specifically (and nothing more than) to get
rid of the pain of a break up, then a brief, problem-oriented therapy is indicated. But if the
client wishes to change something in himself that causes him to thrust himself repetitively
into such painful situations (for example, he continues to become involved with women
who invariably leave him), then longer-term group work is indicated.
The importance of external stress as a factor in premature group termination was
difficult to gauge, since often it appeared secondary to internal forces. A client’s psychic
turmoil may cause disruption of his or her life situation so that secondary external stress
occurs; or a client may focus on an external problem, magnifying it as a means of escaping
anxiety originating from the group therapy. Several clients considered external stress the
chief reason for termination; but in each instance, careful study suggested that external
stress was at best a contributory but not sufficient cause for the dropout. Undue focusing
on external events often seemed to be one manifestation of a denial mechanism that was
helping the client avoid something perceived as dangerous in the group.
In the selection process, therefore, consider an unwarranted focusing on external stress
an unfavorable sign for intensive group therapy, whether it represents an extraordinary
amount of stress or a manifestation of denial.

Group Deviancy. The study of clients who drop out of therapy because they are group
deviants offers a rich supply of information relevant to the selection process. But first the
term deviant must be carefully defined. Almost every group member is deviant in the
sense of representing an extreme in at least one dimension—for example, the youngest
member, the only unmarried member, the sickest, the only Asian-American, the only
student, the angriest, the quietest.
However, one-third of the dropouts in my study deviated significantly from the rest of
the group in areas crucial to their group participation, and this deviancy and its
repercussions were considered the primary reason for their premature termination. The
clients’ behavior in the group varied from those who were silent to those who were loud,
angry group disrupters, but all were isolates and were perceived by the therapists and by
the other members as retarding the progress of the group.
The group and the therapists said of all these members that they “just didn’t fit in.”

Indeed, often the deviants said that of themselves. This distinction is difficult to translate
into objectively measurable factors. The most commonly described characteristics are lack
of psychological-mindedness and lack of interpersonal sensitivity. These clients were
often of lower socioeconomic status and educational level than the rest of the group. The
therapists, when describing the deviants’ group behavior, emphasized that they slowed the
group down. They functioned on a different level of communication from that of the rest
of the group. They remained at the symptom-describing, advice-giving and -seeking, or
judgmental level and avoided discussion of immediate feelings and here-and-now
interaction. Similar results are reported by others.31
An important subcategory of dropouts had chronic mental illness and were making a
marginal adjustment. They had sealed over and utilized much denial and suppression and
were obviously different from other group members in their dress, mannerisms, and
comments. Given the negative psychological impact of high expressed emotionality on
clients with chronic mental illness such as schizophrenia, an intensive interactional group
therapy would be contraindicated in their treatment. Structured, supportive, and
psychoeducational groups are more effective.†
Two clients in the study who did not drop out differed vastly from the other members in
their life experience. One had a history of prostitution, the other had prior problems with
drug addiction and dealing. However, these clients did not differ from the others in ways
that impeded the group’s progress (psychological insight, interpersonal sensitivity, and
effective communication) and never became group deviants.

Group Deviancy: Empirical Research. Considerable social-psychological data from
laboratory group researchu32 helps us understand the fate of the deviant in the therapy
group. Group members who are unable to participate in the group task and who impede
group progress toward the completion of the task are much less attracted to the group and
are motivated to terminate membership.33 Individuals whose contributions fail to match
high group standards for interaction have a high dropout rate, and the tendency to drop out
is particularly marked among individuals who have a lower level of self-esteem.34
The task of group therapy is to engage in meaningful communication with the other
group members, to reveal oneself, to give valid feedback, and to examine the hidden and
unconscious aspects of one’s feelings, behavior, and motivation. Individuals who fail at
this task often lack the required amount of psychological-mindedness, are less
introspective, less inquisitive, and more likely to use self-deceptive defense mechanisms.
They also may be reluctant to accept the role of client and the accompanying implication
that some personal change is necessary.
Research has shown that the individuals who are most satisfied with themselves and
who are inclined to overestimate others’ opinions of them tend to profit less from the
group experience.35 One study demonstrated that group members who did not highly
value or desire personal changes were likely to terminate the group prematurely.36

Questionnaire studies demonstrate that therapy group members who cannot accurately
perceive how others view them are more likely to remain peripheral members.37
What happens to individuals who are unable to engage in the basic group task and are
perceived by the group and, at some level of awareness, by themselves as impeding the
group? Schachter has demonstrated that communication toward a deviant is high initially
and then drops off sharply as the group rejects the deviant member.38
Much research has demonstrated that a member’s satisfaction with the group depends
on his or her position in the group communication network 39 and the degree to which that
member is considered valuable by the other members of the group.40 It also has been
demonstrated that the ability of the group to influence an individual depends partly on the
attractiveness of the group for that member and partly on the degree to which the member
communicates with the others in the group.41 An individual’s status in a group is conferred
by the group, not seized by the individual. Lower status diminishes personal well-being
and has a negative impact on one’s emotional experience in social groups.42 This is an
important finding, and we will return to it: Lower group status diminishes personal well-
being; in other words, it is antitherapeutic.
It is also well known from the work of Sherif43 and Asch44 that an individual will often
be made exceedingly uncomfortable by a deviant group role, and there is evidence that
such individuals will manifest progressively more anxiety and unease if unable to speak
about their position.45 Lieberman, Yalom, and Miles demonstrated that deviant group
members (members considered “out of the group” by the other members or who grossly
misperceived the group norms) had virtually no chance of benefiting from the group and
an increased likelihood of suffering negative consequences.46
To summarize, experimental evidence suggests that the group deviant, compared with
other group members, derives less satisfaction from the group, experiences anxiety, is less
valued by the group, is less likely to be influenced by or to benefit from the group, is more
likely to be harmed by the group, and is far more likely to terminate membership.
These experimental findings coincide with the experience of deviants in the therapy
groups I studied. Of the eleven deviants, one did not terminate prematurely—a middle-
aged, isolated, rigidly defended man. This man managed to continue in the group because
of the massive support he received in concurrent individual therapy. However, he not only
remained an isolate in the group but, in the opinion of the therapists and the other
members, he impeded the progress of the group. What happened in that group was
remarkably similar to the phenomena in Schachter’s laboratory groups described above.47
At first, considerable group energy was expended on the deviant; eventually the group
gave up, and the deviant was, to a great extent, excluded from the communicational
network. But the group could never entirely forget the deviant, who slowed the pace of the
work. If there is something important going on in the group that cannot be talked about,
there will always be a degree of generalized communicative inhibition. With a
disenfranchised member, the group is never really free; in a sense, it cannot move much
faster than its slowest member.

Now, let’s apply these research findings and clinical observations to the selection
process. The clients who will assume a deviant role in therapy groups are not difficult to
identify in screening interviews. Their denial, their de-emphasis of intrapsychic and
interpersonal factors, their unwillingness to be influenced by interpersonal interaction, and
their tendency to attribute dysphoria to somatic and external environmental factors will be
evident in a carefully conducted interview. Some of these individuals stand out by virtue
of significantly greater impairment in function. They are often referred to group therapy
by their individual therapists, who feel discouraged or frustrated by the lack of progress.
Occasionally, postponing entry into group therapy to provide more time for some clients
to benefit from pharmacotherapy and to consolidate some stability make may group
therapy possible at a later time, but in conjunction with individual treatment and
management, not in place of it.
Thus, it is not difficult to identify these clients. Clinicians often err in assuming that
even if certain clients will not click with the rest of the group, they will nevertheless
benefit from the overall group support and the opportunity to improve their socializing
techniques. In my experience, this expectation is not realized. The referral is a poor one,
with neither the client nor the group profiting. Eventually the group will extrude the
deviant. Therapists also tend to divest overtly and covertly from such clients, putting their
therapautic energies into those clients who reward the effort.48
Rigid attitudes coupled with proselytizing desires may rapidly propel an individual into
a deviant position. A very difficult client to work with in long-term groups is the
individual who employs fundamentalist religious views in the service of denial. The
defenses of this client are often impervious to ordinarily potent group pressures because
they are bolstered by the norms of another anchor group—the particular religious sect. To
tell the client that he or she is applying certain basic tenets with unrealistic literalness is
often ineffective, and a frontal assault on these defenses merely rigidifies them.
To summarize, it is important that the therapist screen out clients who are likely to
become marked deviants in the group for which they are being considered. Clients become
deviants because of their interpersonal behavior in the group sessions, not because of a
deviant lifestyle or history. There is no type of past behavior too deviant for a group to
accept once therapeutic group norms have been established. I have seen individuals who
have been involved with prostitution, exhibitionism, incest, voyeurism, kleptomania,
infanticide, robbery, and drug dealing accepted by middle-class straight groups.

Problems of Intimacy. Several clients dropped out of group therapy because of conflicts
associated with intimacy, manifested in various ways: (1) schizoid withdrawal, (2)
maladaptive self-disclosure (promiscuous self-disclosures or pervasive dread of self-
disclosure), and (3) unrealistic demands for instant intimacy.v
Several clients who were diagnosed as having schizoid personality disorder (reflecting
their social withdrawal, interpersonal coldness, aloofness, introversion, and tendency
toward autistic preoccupation) experienced considerable difficulty relating and

communicating in the group. Each had begun the group with a resolution to express
feelings and to correct previous maladaptive patterns of relating. They failed to
accomplish this aim and experienced frustration and anxiety, which in turn further blocked
their efforts to speak. Their therapists described their group role as “isolate,” “silent
member,” “peripheral,” and “nonrevealer.”
Most of these group members terminated treatment thoroughly discouraged about the
possibility of ever obtaining help from group therapy. Early in the course of a new group, I
have occasionally seen such clients leave the group having benefited much from
therapeutic factors such as universality, identification, altruism, and development of
socializing techniques. If they remain in the group, however, the group members, in time,
often grow impatient with the schizoid member’s silence and weary of drawing them out
(“playing twenty questions,” as one group put it) and turn against them.
Another intimacy-conflicted client dropped out for different reasons: his fears of his
own aggression against other group members. He originally applied for treatment because
of a feeling of wanting to explode: “a fear of killing someone when I explode … which
results in my staying far away from people.” He participated intellectually in the first four
meetings he attended, but was frightened by the other members’ expression of emotion.
When a group member monopolized the entire fifth meeting with a repetitive, tangential
discourse, he was enraged with the monopolizer and with the rest of the group members
for their complacency in allowing this to happen and, with no warning, abruptly
terminated therapy.
Other clients experienced a constant, pervasive dread of self-disclosure, which
precluded participation in the group and ultimately resulted in their dropping out. Still
others engaged in premature, promiscuous self-disclosure and abruptly terminated. Some
clients made such inordinate demands on their fellow group members for immediate,
prefabricated intimacy that they created a nonviable group role for themselves. One early
dropout unsettled the group in her first meeting by announcing to the group that she
gossiped compulsively and doubted that she would be able to maintain people’s
confidentiality.
Clients with severe problems in the area of intimacy present a particular challenge to
the group therapist both in selection and in therapeutic management (to be considered in
chapter 13). The irony is that these individuals are the very ones for whom a successful
group experience could be particularly rewarding. A study of experiential groups found
that individuals with constricted emotionality, who are threatened by the expression of
feelings by others, and have difficulty experiencing and expressing their own emotional
reactions learn more and change more than others as a result of their group experience,
even though they are significantly more uncomfortable in the group.49 Therefore, these
clients, whose life histories are characterized by ungratifying interpersonal relationships,
stand to profit much from successfully negotiating an intimate group experience. Yet, if
their interpersonal history has been too deprived, they will find the group too threatening
and will drop out of therapy more demoralized than before.50 Clients who crave social
connectedness but are hampered by poor interpersonal skills are particularly prone to

psychological distress.51 These individuals are frustrated and distressed being in a group
bursting with opportunities for connectedness that they cannot access for themselves.52
Thus, clients with problems in intimacy represent at the same time a specific indication
and contraindication for group therapy. The problem, of course, is how to identify and
screen out those who will be overwhelmed in the group. If only we could accurately
quantify this critical cutoff point! The prediction of group behavior from pretherapy
screening sessions is a complex task that I will discuss in detail in the next chapter.
Individuals with severe character and narcissistic pathology and a pervasive dread of
self-disclosure may be unfavorable candidates for interactional group therapy. But if such
individuals are dissatisfied with their interpersonal styles, express a strong motivation for
change, and manifest curiosity about their inner lives, then they stand a better chance of
benefiting from a therapy group. The group interaction may cause these individuals
intense anxiety about losing their sense of self and autonomy. They crave connectedness
yet fear losing themselves in that very process. Interpersonal defenses against these
vulnerabilities, such as withdrawal, devaluation, or self-aggrandizement, may push the
group member into a deviant group role.53 Mildly or moderately schizoid clients and
individuals with avoidant personality disorder, on the other hand, are excellent candidates
for group therapy and rarely fail to benefit from it.
Greater caution should be exercised when the therapist is seeking a replacement
member for an already established, fast-moving group. Often, combining individual and
group therapy may be necessary to launch or sustain vulnerable clients in the group. The
added support and containment provided by the individual therapist may diminish the
sense of risk for the client.54

Fear of Emotional Contagion. Several clients who dropped out of group therapy reported
being adversely affected by hearing the problems of the other group members. One man
stated that during his three weeks in the group, he was very upset by the others’ problems,
dreamed about them every night, and relived their problems during the day. Other clients
reported being upset by one particularly disturbed client in each of their groups. They
were all frightened by seeing aspects of the other client in themselves and feared that they
might become as mentally ill as the severely disturbed client or that continued exposure to
that member would evoke a personal regression. Another client in this category who
bolted from the first group meeting thirty minutes early and never returned described a
severe revulsion toward the other group members: “I couldn’t stand the people in the
group. They were repulsive. I got upset seeing them trying to heap their problems on top
of mine. I didn’t want to hear their problems. I felt no sympathy for them and couldn’t
bear to look at them. They were all ugly, fat, and unattractive.” This client had a lifelong
history of being upset by other people’s illnesses and avoiding sick people. Once when her
mother fainted, she “stepped over her” to get away rather than trying to help. Other
clinicians have noted that clients in this category have a long-term proclivity to avoid sick
people, and, if they had been present at an accident were the first to leave or tended to

look the other way.55
Such concern about contagion has many possible dynamics. Many clients with
borderline personality disorder report such fears (it is a common phenomenon in inpatient
group therapy), and it is often regarded as a sign of permeable ego boundaries and an
inability to differentiate oneself from significant others in one’s environment.
A fear of emotional contagion, unless it is extremely marked and clearly manifest in the
pretherapy screening procedure, is not a particularly useful index for selection or
exclusion for a group. Generally, it is difficult to predict this behavior from screening
interviews. Furthermore, fear of emotional contagion is not in itself sufficient cause for
failure. Therapists who are sensitive to the problem can deal with it effectively in the
therapeutic process. Occasionally, clients must gradually desensitize themselves: I have
known individuals who dropped out of several therapy groups but who persevered until
they were finally able to remain in one. These attitudes by no means rule out group
therapy. The therapist may help by clarifying for the client the crippling effects of his or
her attitudes toward others’ distress. How can one develop friendships if one cannot bear
to hear of another’s difficulties? If the discomfort can be contained, the group may well
offer the ideal therapeutic format for such a client.

Other Reasons. The other reasons for group therapy dropouts—inability to share the
therapist, complications of concurrent individual and group therapy, early provocateurs,
problems in orientation to therapy, and complications arising from subgrouping—were
generally a result less of faulty selection than of faulty therapeutic technique; they will be
discussed in later chapters. None of these categories, though, belongs solely under the
rubric of selection or therapy technique. For example, some clients terminated because of
an inability to share the therapist. They never relinquished the notion that progress in
therapy was dependent solely on the amount of goods (time, attention, and so on) they
received from the group therapist.
Although it may have been true that these clients tended to be excessively dependent
and authority oriented, it was also true that they had been incorrectly referred to group
therapy. They had all been in individual therapy, and the group was considered a method
of therapy weaning. Obviously, group therapy is not a modality to be used to facilitate the
termination phase of individual therapy, and the therapist, in pretherapy screening, should
be alert to inappropriate client referrals. Sometimes clients’ strong reluctance to relinquish
individual therapy will prevent them engaging in group therapy.†
As we saw in earlier chapters, there is compelling evidence that the strength of the
therapeutic alliance predicts therapy outcome. Conversely, problems with the alliance,
such as client-therapist disagreement about the goals, tasks, or therapy relationship, are
associated with premature terminations and failure. A study of ten dropouts noted that
several clients had been inadequately prepared for the group.56 The therapist had been
unclear about the reasons for placing them in a group. No clear set of goals had been
formulated, and some clients were suspicious of the therapists’ motives—questioning

whether they had been placed in the group simply because the group needed a warm body.
Some were wounded by being placed in a group with significantly dysfunctional
members. They took this as a statement of the therapist’s judgment of their condition.
Some were wounded simply by being referred to a group, as though they were being
reduced from a state of specialness to a state of ordinariness. Still others left the group
because of a perceived imbalance in the giving-receiving process. They felt that they gave
far more than they received in the group.
CRITERIA FOR INCLUSION
The most important clinical criterion for inclusion is the most obvious one: motivation.57
The client must be highly motivated for therapy in general and for group therapy in
particular. It will not do to start group therapy because one has been sent—whether by
spouse, probation officer, individual therapist, or any individual or agency outside oneself.
Many erroneous prejudgments of the group may be corrected in the preparation procedure
(see chapter 10), but if you discern a deeply rooted unwillingness to accept responsibility
for treatment or deeply entrenched unwillingness to enter the group, you should not accept
that person as a group therapy member.
Most clinicians agree that an important criterion for inclusion is whether a client has
obvious problems in the interpersonal domain: for example, loneliness, shyness and social
withdrawal, inability to be intimate or to love, excessive competitiveness, aggressivity,
abrasiveness, argumentativeness, suspiciousness, problems with authority, narcissism, an
inability to share, to empathize, to accept criticism, a continuous need for admiration,
feelings of unlovability, fears of assertiveness, obsequiousness, and dependency. In
addition, of course, clients must be willing to take some responsibility for these problems
or, at the very least, acknowledge them and entertain a desire for change.
Some clinicians suggest group therapy for clients who do not work well in individual
therapy as a result of their limited ability to report on events in their life (because of blind
spots or because of ego syntonic character pathology.)58
Impulsive individuals who find it difficult to control the need to act immediately on
their feelings usually work better in groups than in individual therapy.59 The therapist
working with these clients in individual therapy often finds it difficult to remain both
participant and observer, whereas in the group these two roles are divided among the
members: some members may, for example, rush to battle with the impulsive client, while
others egg them on (“Let’s you and him fight”), and others act as disinterested, reliable
witnesses whose testimony the impulsive client is often far more willing to trust than the
therapist’s.
In cases where interpersonal problems are not paramount (or not obvious to the client),
group therapy may still be the treatment of choice. For example, clients who are extremely
intellectualized may do better with the affective stimuli available in a group. Other clients

fare poorly in individual therapy because of severe problems in the transference: they may
not be able to tolerate the intimacy of the dyadic situation, either so distorting the
therapeutic relationship or becoming so deeply involved with (or oppositional to) the
therapist that they need the reality testing offered by other group members to make therapy
possible. Others are best treated in a group because they characteristically elicit strong
negative counter-transference from an individual therapist.60
• Grant, a thirty-eight-year-old man referred to group therapy by his female
individual therapist, struggled with anger and a near-phobic avoidance of
tenderness or dependence that he believed was related to physical abuse he
suffered at the hands of his brutal father. When his young son’s physical
playfulness became frightening to him, he sought individual therapy because of his
concern that he would be an inadequate or abusive father.
At first the individual therapy progressed well, but soon the therapist became
uneasy with Grant’s aggressive and crude sexual feelings toward her. She became
particularly concerned when Grant suggested that he could best express his
gratitude to her through sexual means. Stymied in working this through, yet
reluctant to end the therapy because of Grant’s gains, the therapist referred him to
a therapy group, hoping that the concurrent group and individual format would
dilute the intensity of the transference and countertransference. The group offered
so many alternatives for both relatedness and confrontation that Grant’s treatment
was able to proceed effectively in both venues.
Many clients seek therapy without an explicit interpersonal complaint. They may cite
the common problems that propel the contemporary client into therapy: a sense of
something missing in life, feelings of meaninglessness, diffuse anxiety, anhedonia, identity
confusion, mild depression, self-derogation or self-destructive behavior, compulsive
workaholism, fears of success, alexithymia.61 But if one looks closely, each of these
complaints has its interpersonal underpinnings, and each generally may be treated as
successfully in group therapy as in individual therapy.62
Research on Inclusion Criteria
Any systematic approach to defining criteria for inclusion must issue from the study of
successful group therapy participants. Unfortunately, as I discussed at the beginning of
this chapter, such research is extraordinarily difficult to control. I should note that
prediction of outcome in individual therapy research is equally difficult, and recent
reviews stress the paucity of successful, clinically relevant research.63
In a study of forty clients in five outpatient therapy groups through one year of group
therapy, my colleagues and I attempted to identify factors that were evident before group
therapy that might predict successful outcome.64 Outcome was evaluated and correlated
with many variables measured before the start of therapy. Our results indicated that none
of the pretherapy factors measured were predictive of success in group therapy, including

level of psychological sophistication, therapists’ prediction of outcome, previous self-
disclosure, and demographic data. However, two factors measured early in therapy (at the
sixth and the twelfth meetings) predicted success one year later: the clients’ attraction to
the group and the clients’ general popularity in the group.65 The finding that popularity
correlated highly with successful outcome has some implications for selection, because
researchers have found that high self-disclosure, activity in the group, and the ability to
introspect were some of the prerequisites for group popularity.66 Recall that popularity and
status in a group accrues to individuals who model the behaviors that advance the group’s
achievement of its goals.67
The Lieberman, Yalom, and Miles study (see chapter 16) demonstrated that, in pregroup
testing, those who were to profit most from the group were those who highly valued and
desired personal change; who viewed themselves as deficient both in understanding their
own feelings and in their sensitivity to the feelings of others; who had high expectations
for the group, anticipating that it would provide relevant opportunities for communication
and help them correct their deficiencies.68
Melnick and Rose, in a project involving forty-five encounter group members,
determined at the start of the group each member’s risk-taking propensity and expectations
about the quality of interpersonal behavior to be experienced in the group. They then
measured each member’s actual behavior in the group (including self-disclosure, feedback
given, risk taking, verbal activity, depth of involvement, attraction to the group).69 They
found that both high-risk propensity and more favorable expectations correlated with
therapeutically favorable behavior in the group.
The finding that a positive expectational set is predictive of favorable outcome has
substantial research support: the more a client expects therapy—either group or individual
—to be useful, the more useful will it be.†70 The role of prior therapy is important in this
regard: experienced clients have more positive and more realistic expectations of therapy.
Agreement between therapist and client about therapy expectations strengthens the
therapeutic alliance, which also predicts better therapy outcome.71 This relationship
between positive expectational set and positive outcome has important implications not
only for the selection process but also for the preparation of clients for therapy. As I will
discuss in chapter 10, it is possible, through proper preparation, to create a favorable
expectational set.
The Client’s Effect on Other Group Members
Other inclusion criteria become evident when we consider the other members of a group
into which the client may be placed. Thus far, for pedagogical clarity, I have
oversimplified the problem by attempting to identify only absolute criteria for inclusion or
exclusion. Unlike individual therapy recruitment, where we need consider only whether
the client will profit from therapy and whether he or she and a specific therapist can
establish a working relationship, recruitment for group therapy cannot, in practice, ignore

the other group members.
It is conceivable, for example, that a depressed suicidal client or a compulsive talker
might derive some benefit from a group, but also that such a client’s presence would
render the group less effective for several other members. Group therapists not only
commit themselves to the treatment of everyone they bring into the group, they also
commit all of their other members to that individual. For example, Grant, the client
described earlier in this chapter, elicited very powerful reactions from the women in the
early phases of his group therapy. At one point a female member of the group responded
to one of a series of Grant’s angry attacks with, “I am trying to understand where Grant is
coming from, but how much longer must I sacrifice myself and my progress for his
therapy?”
Conversely, there may be clients who would do well in a variety of treatment modalities
but are placed in a group to meet some specific group needs. For example, some groups at
times seem to need an aggressive member, or a strong male, or a soft feminine member.
While clients with borderline personality disorder often have a stormy course of therapy,
some group therapists intentionally introduce them into a group because of their beneficial
influence on the group therapy process. Generally, such individuals are more aware of
their unconscious, less inhibited, and less dedicated to social formality, and they may lead
the group into a more candid and intimate culture. Considerable caution must be
exercised, however, in including a member whose ego strength is significantly less than
that of the other members. If these clients have socially desirable behavioral traits and are
valued by the other members because of their openness and deep perceptivity, they will
generally do very well. If, however, their behavior alienates others, and if the group is so
fast moving or threatening that they retard the group rather than lead it, then they will be
driven into a deviant role and their experience is likely to be countertherapeutic.
The Therapist’s Feeling Toward the Client
One final, and important, criterion for inclusion is the therapist’s personal feeling toward
the client. Regardless of the source, the therapist who strongly dislikes or is disinterested
in a client (and cannot understand or alter that reaction) should refer that person
elsewhere. This caveat is obviously relative, and you must establish for yourself which
feelings would preclude effective therapy.
It is my impression that this issue is somewhat more manageable for group therapists
than for individual therapists. With the consensual validation available in the group from
other members and from the co-therapist, many therapists find that they are more often
able to work through initial negative feelings toward clients in group therapy than in
individual therapy. Nonetheless there is evidence that therapist hostility often results in
premature termination in group therapy.72 As therapists gain experience and self-
knowledge, they usually develop greater generosity and tolerance and find themselves
actively disliking fewer and fewer clients. Often the antipathy the therapist experiences
reflects the client’s characteristic impact on others and thus constitutes useful data for

therapy.†
AN OVERVIEW OF THE SELECTION PROCEDURE
The material I have presented thus far about selection of clients may seem disjunctive. I
can introduce some order by applying to this material a central organizing principle—a
simple punishment-reward system. Clients are likely to terminate membership in a therapy
group prematurely—and hence are poor candidates—when the punishments or
disadvantages of group membership outweigh the rewards or the anticipated rewards. By
“punishments” and “disadvantages,” I mean the price the client must pay for group
membership, including an investment of time, money, and energy as well as a variety of
uncomfortable feelings arising from the group experience, including anxiety, frustration,
discouragement, and rejection.
The client should play an important role in the selection process. It is preferable that
one deselect oneself before entering the group rather than undergo the discomfort of
dropping out of the group. However, the client can make a judicious decision only if
provided with sufficient information: for example, the nature of the group experience, the
anticipated duration of therapy, and what is expected of him or her in the group (see
chapter 10).
The rewards of membership in a therapy group consist of the various satisfactions
members obtain from the group. Let us consider those rewards, or determinants of group
cohesiveness, that are relevant to the selection of clients for group therapy.73
Members are satisfied with their groups (attracted to their groups and likely to continue
membership in them) if:
1. They view the group as meeting their personal needs—that is, their goals in
therapy.
2. They derive satisfaction from their relationships with the other members.
3. They derive satisfaction from their participation in the group task.
4. They derive satisfaction from group membership vis-à-vis the outside world.
These are important factors. Each, if absent or of negative value, may outweigh the
positive value of the others and result in premature termination. Let us consider each in
turn.
Does the Group Satisfy Personal Needs?
The explicit personal needs of group members are at first expressed in their chief
complaint, their purpose for seeking therapy. These personal needs are usually couched in

terms of relief from suffering or, less frequently, in terms of self-understanding or personal
growth. Several factors are important here: there must be significant personal need; the
group must be viewed as an agent with the potential of meeting that need; and the group
must be seen, in time, as making progress toward meeting that need.
Clients must, of course, have some discomfort in their lives to provide the required
motivation for change. The relationship between discomfort and suitability for group
therapy is not linear but curvilinear. Clients with too little discomfort (coupled with only a
modest amount of curiosity about groups or themselves) are usually unwilling to pay the
price for group membership.
Clients with moderately high discomfort may, on the other hand, be willing to pay a
high price, provided they have faith or evidence that the group can and will help. From
where does this faith arise? There are several possible sources:
• Endorsement of group therapy by the mass media, by friends who have had a
successful group therapy experience, or by a previous individual therapist,
referring agency, or physician
• Explicit preparation by the group therapist (see chapter 10)
• Belief in the omniscience of authority figures
• Observing or being told about improvement of other group members
• Observing changes in oneself occurring early in group therapy
Clients with exceedingly high discomfort stemming from extraordinary environmental
stress, internal conflicts, inadequate ego strength, or some combination of these may be so
overwhelmed with anxiety that many of the activities of the long-term dynamic group
seem utterly irrelevant. Initially groups are unable to meet highly pressing personal needs.
Dynamic, interactional group therapy is not effective or efficient in management of
intense crisis and acute psychological distress.
Greatly disturbed clients may be unable to tolerate the frustration that occurs as the
group gradually evolves into an effective therapeutic instrument. They may demand
instant relief, which the group cannot supply—it is not designed to do so. Or they may
develop anxiety-binding defenses that are so interpersonally maladaptive (for example,
extreme projection or somatization) as to make the group socially nonviable for them.
Again, it is not group therapy per se that is contraindicated for clients with exceedingly
high discomfort, but longer-term dynamic group therapy. These acutely disturbed clients
may be excellent candidates for a crisis group or for a specialized problem-oriented group
—for example, a cognitive-behavioral group for clients with depression or panic
disorder.† There too, however, they will need to participate in the group work; the
difference is in the nature and focus of the work.74
Some clients facing an urgent major decision like divorce, abortion, or relinquishing
custody of a child may not be good candidates for a dynamic group. But later, after the
decision has been made, they may benefit from group therapy in dealing with the
psychological and social ramifications of their choice.

Individuals variously described as non–psychologically minded, nonintrospective, high
deniers, psychological illiterates, psychologically insensitive, and alexithymic may be
unable to perceive the group as meeting their personal needs. In fact, they may perceive an
incompatibility between their personal needs and the group goals. Psychological-
mindedness is a particularly important variable, because it helps individuals engage in the
“work” of therapy75 that produces positive outcomes. Without it, clients may reason,
“How can looking at my relations with the group members help me with my bad nerves?”
Satisfaction from Relationships with Other Members
Group members derive satisfaction from their relationships with other group members,
and often this source of attraction to the group may dwarf the others. The importance of
relationships among members both as a source of cohesiveness and as a therapeutic factor
was fully discussed in chapter 3, and I need pause here only to reflect that it is rare for a
client to continue membership in the prolonged absence of interpersonal satisfaction.
The development of interpersonal satisfaction may be a slow process. Psychotherapy
clients are often contemptuous of themselves and are therefore likely to be initially
contemptuous of their fellow group members. They have had, for the most part, few
gratifying interpersonal relationships in the past and have little trust or expectation of
gaining anything from close relationships with the other group members. Often they may
use the therapist transitionally: by relating positively to the therapist at first, they may
more easily grow closer to one another.76
Satisfaction from Participation in Group Activities
The satisfaction that clients derive from participation in the group task is largely
inseparable from the satisfaction they derive from relationships with the other members.
The group task—to achieve a group culture of intimacy, acceptance, introspection,
understanding, and interpersonal honesty—is fundamentally interpersonal, and research
with a wide variety of groups has demonstrated that participation in the group task is an
important source of satisfaction for the group members.77 Clients who cannot introspect,
reveal themselves, care for others, or manifest their feelings will derive little gratification
from participation in group activities. Such clients include many of the types discussed
earlier: for example, the schizoid personality, clients with other types of overriding
intimacy problems, the deniers, the somatizers, the organically impaired, and the mentally
retarded. These individuals are better treated in a homogeneous, problem-specific group
that has a group task consonant with their abilities.
Satisfaction from Pride in Group Membership
Members of many kinds of groups derive satisfaction from membership because the

outside world regards their group as highly valued or prestigious. Not so for therapy
groups because of members’ share. Therapy group members will, however, usually
develop some pride in their group: for example, they will defend it if it is attacked by new
members. They may feel superior to outsiders—to those “in denial,” to individuals who
are as troubled as they but lack the good sense to join a therapy group. If clients manifest
extraordinary shame at membership and are reluctant to reveal their membership to
intimate friends or even to spouses, then their membership will appear to them dissonant
with the values of other important anchor groups. It is not likely that such clients will
become deeply attracted to the group. Occasionally, outside groups (family, military, or,
more recently, industry) will exert pressure on the individual to join a therapy group.78
Groups held together only by such coercion are tenuous at first, but the evolving group
process may generate other sources of cohesiveness.
SUMMARY
Selection of clients for group therapy is, in practice, a process of deselection: group
therapists exclude certain clients from consideration and accept all others. Although
empirical outcome studies and clinical observation have generated few inclusion criteria,
the study of failures in group therapy, especially of clients who drop out early in the
course of the group, provides important exclusion criteria.
Clients should not be placed in a group if they are likely to become groups deviants.
Deviants stand little chance of benefiting from the group experience and a fair chance of
being harmed by it. A group deviant is one who is unable to participate in the group task.
Thus, in a heterogeneous, interactional group, a deviant is one who cannot or will not
examine himself and his relationship with others, especially with the other members of the
group. Nor can he accept his responsibility for his life difficulties. Low psychological-
mindedness is a key criterion for exclusion from a dynamic therapy group.
Clients should be excluded from long-term groups if they are in the midst of a life crisis
that can be more efficiently addressed in brief, problem-specific groups or in other therapy
formats.
Conflicts in the sphere of intimacy represent both indication and contraindication for
group therapy. Group therapy can offer considerable help in this domain—yet if the
conflicts are too extreme, the client will choose to leave (or be extruded) by the group.
The therapist’s task is to select those clients who are as close as possible to the border
between need and impossibility. If no markers for exclusion are present, the vast majority
of clients seeking therapy can be treated in group therapy.

Chapter 9
THE COMPOSITION OF THERAPY GROUPS
A chapter on group composition might at first glance seem anachronistic in the
contemporary practice of group psychotherapy. Economic and managed care pressures on
today’s group therapist may make the idea of mindfully composing a psychotherapy group
seem an impractical luxury. How can one think about the ideal method of composing
therapy groups when pressures for target symptom relief, homogeneous groups, structured
meetings, and brevity of therapy are the order of the day? Moreover, empirical research
indicates that the briefer and more structured the group, the less important are
compositional issues.1 To make matters worse, research in group composition is doubtless
one of the most complex and confusing areas in the group therapy literature. So what is
the point of including a chapter on group composition in this text?
In this chapter my aim is to show that the principles of group composition are relevant
in all forms of therapy groups, even the most structured and seemingly homogeneous.
Group composition principles help group leaders understand the process within each
group and tailor their work to meet the requirements of each client. If therapists fail to
attend to issues of diversity in interpersonal, cognitive, personality, and cultural
dimensions, they will fall prey to a simplistic and ineffective “one-size-fits-all” approach
to group therapy. The research on group composition is voluminous and complex. Readers
who are less interested in research detail may prefer in this chapter to focus on the section
summaries and the final overview.
Let us begin with a thought experiment. Imagine the following situation: An ambulatory
mental health clinic or counseling center with ten group therapists ready to form groups
and seventy clients who, on the basis of the selection criteria outlined thus far, are suitable
group therapy candidates. Is there an ideal way to compose these ten groups?
Or imagine this more common, analogous situation: An intake coordinator deems a
client a suitable candidate for group therapy, and there are several groups operating in the
clinic, each with one vacancy. Into which group should the client go? Which group would
offer the best fit?† Both situations raise a similar question: Is there a superior method of
composing or blending a group? Will the proper blend of individuals form an ideal group?
Will the wrong blend remain inharmonious and never coalesce into a working group?
I believe that it is important to establish valid compositional principles to help us
determine which clients should go into which groups. We grope in the dark if we try to
build a group or fill a vacancy without any knowledge of the organization of the total
system. The stakes are high: first, a number of comembers will be affected by the decision
to introduce a particular client into a group, and second, the brief frame of contemporary
group treatment leaves little time for correction of errors.
As in preceding chapters, I will devote particular attention to groups with ambitious
goals that focus on here-and-now member interaction. But principles of composition also

apply to homogeneous, problem-specific, cognitive-behavioral, or psychoeducational
groups. Keep in mind that even in such groups, homogeneity in one dimension, such as
diagnosis, can initially mask important heterogenity (for example, stage and severity of
illness) that may powerfully interfere with the group’s ability to work well together.
First, let me clarify what I mean by right and wrong “blends.” Blends of what? What
are the ingredients of our blend? Which of the infinite number of human characteristics
are germane to the composition of an interactional therapy group? Since each member
must continually communicate and interact with the other members, it is the interaction of
members that will dictate the fate of a group. Therefore, if we are to deal intelligently with
group composition, we must aim for a mix that will allow the members to interact in some
desired manner. The entire procedure of group composition and selection of group
members is thus based on the important assumption that we can, with some degree of
accuracy, predict the interpersonal or group behavior of an individual from pretherapy
screening. Are we able to make that prediction?
THE PREDICTION OF GROUP BEHAVIOR
In the previous chapter, I advised against including individuals whose group behavior
would render their own therapy unproductive and impede the therapy of the rest of the
group. Generally, predictions of the group behavior of individuals with extreme, fixed,
maladaptive interpersonal behavior (for example, the sociopathic or the floridly manic
client) are reasonably accurate: in general, the grosser the pathology, the greater the
predictive accuracy.
In everyday clinical practice, however, the problem is far more subtle. Most clients who
apply for treatment have a wider repertoire of behavior, and their ultimate group behavior
is far less predictable. Let us examine the most common procedures used to predict
behavior in the group.
The Standard Diagnostic Interview
The most common method of screening clients for groups is the standard individual
interview. The interviewer, on the basis of data on environmental stresses, personal
history, and inferences about motivation for treatment and ego strength, attempts to predict
how the individual will behave in the group. These predictions, based on observations of a
client’s behavior in the dyadic situation, are often hazy and inaccurate. Later in the chapter
I will present some strategies to increase the validity of these preliminary inferences.
One of the traditional end products of the mental health interview is a diagnosis that, in
capsule form, is meant to summarize the client’s condition and convey useful information
from practitioner to practitioner. But does it succeed in offering practical information?

Group therapists will attest it does not! Psychiatric diagnoses based on standard
classificatory systems (for example, DSM-IV-TR) are, at best, of limited value as an
indicator of interpersonal behavior. Diagnostic nomenclature was never meant for this
purpose; it stemmed from a disease-oriented medical discipline. It is based primarily on
the determination of syndromes according to aggregates of certain signs and symptoms.
Personality is generally classified in a similar fashion, emphasizing discrete categories of
interpersonal behavior rather than describing interpersonal behavior as it is actually
manifested.2
The 2000 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) is an
improvement over earlier psychiatric diagnostic systems, and it pays far more attention to
personality. It codes personality on a specific axis (Axis II) and recognizes that an
individual may demonstrate clustering of personality pathology in more than one area,
apart from (or in addition to) Axis I psychiatric disorders. The DSM-IV-TR provides a
sharper demarcation between severe and less severe personality disorders and in general
has a more empirical foundation than previous DSM systems.3
Nonetheless, the DSM-IV-TR, along with the most recent International Classification
of Disease (ICD-10), has marked limitations for practitioners working with clients whose
interpersonal distress and disturbance do not fit neatly into syndrome definitions.
Contemporary diagnosis also emphasizes discrete and observable behavior, with little
attention paid to the inner life of the individual.4
Overall, the standard intake interview has been shown to have little value in predicting
subsequent group behavior.5 For example, one study of thirty clients referred to group
therapy demonstrated that the intake interviewers’ ratings of five important factors—
motivation for group therapy, verbal skills, chronicity of problems, history of object
relations, and capacity for insight—had no predictive value for the client’s subsequent
group behavior (for example, verbal activity and responsivity to other members and to the
leader).6
That a diagnostic label fails to predict much about human behavior should neither
surprise nor chagrin us. No label or phrase can adequately encompass an individual’s
essence or entire range of behavior.7 Any limiting categorization is not only erroneous but
offensive, and stands in opposition to the basic human foundations of the therapeutic
relationship. In my opinion, the less we think (during the process of psychotherapy) in
terms of diagnostic labels, the better. (Albert Camus once described hell as a place where
one’s identity was eternally fixed and displayed on personal signs: Adulterous Humanist,
Christian Landowner, Jittery Philosopher, Charming Janus, and so on.8 To Camus, hell is
where one has no way of explaining oneself, where one is fixed, classified—once and for
all time.)
Standard Psychological Testing
The standard psychological diagnostic tests—among them the Rorschach test, the

Minnesota Multiphasic Personality Inventory (MMPI), the Thematic Apperception Test
(TAT), the Sentence Completion test, and the Draw-a-Person test—have failed to yield
predictions of value to the group therapist.9
Specialized Diagnostic Procedures
The limited value of standard diagnostic procedures suggests that we need to develop new
methods of assessing interpersonal behavior. Slowly, the field is beginning to assess
personality traits and tendencies more accurately to improve our methods of matching
clients to therapy.10 Recent clinical observations and research suggest several promising
directions in two general categories:
1. A formulation of an interpersonal nosological system. If the critical variable in
group therapy selection is interpersonal in nature, why not develop an
interpersonally based diagnostic scheme?
2. New diagnostic procedures that directly sample group-relevant behavior
An Interpersonal Nosological System. The first known attempt to classify mental illness
dates back to 1700 B.C.,11 and the intervening centuries have seen a bewildering number
of systems advanced, each beset with its own internal inconsistency. The majority of
systems have classified mental illness according to either symptoms or presumed etiology.
The advent of the object-relations and interpersonal systems of conceptualizing
psychopathology, together with the increase in the number of people seeking treatment for
less severe problems in living,12 stimulated more sophisticated attempts to classify
individuals according to interpersonal styles of relating.† In previous generations
psychotherapy researchers interested in the impact of personality variables on the
individual’s participation in groups measured such variables as externalization and
resistance,13 perceived mastery and learned resourcefulness, 14 dogmatism,15 preference
for high or low structure,16 social avoidance,17 locus of control,18 interpersonal trust,19
and social risk-taking propensity.20
It is of interest to note that some of the contemporary empirical schema of interpersonal
relationships draw heavily from earlier clinical conceptualizations. Karen Horney’s
midcentury model has been particularly relevant in new formulations. Horney viewed
troubled individuals as moving exaggeratedly and maladaptively toward, against, or away
from other people and described interpersonal profiles of these types and various
subtypes.21
Bowlby’s work on attachment22 has also spawned new work that categorizes
individuals on the basis of four fundamental styles of relationship attachment: 1) secure;
2) anxious; 3) detached or dismissive and avoidant; and 4) fearful and avoidant.23 Some
therapists feel that these attachment styles are so important that the therapist’s recognition
and appropriate therapeutic responsiveness to them may make or break treatment.24

Contemporary interpersonal theorists† have attempted to develop a classification of
diverse interpersonal styles and behavior based on data gathered through interpersonal
inventories (often the Inventory of Interpersonal Problems, IIP).25 They then place this
information onto a multidimensional, interpersonal circumplex (a schematic depiction of
interpersonal relations arranged around a circle in two-dimensional space; see figure
9.1).26
Two studies that used the interpersonal circumplex in a twelve-session training group of
graduate psychology students generated the following results:
1. Group members who were avoidant and dismissive were much more likely to
experience other group members as hostile.
2. Group members who were anxious about or preoccupied with relationships saw
other members as friendly.
3. Strongly dominant individuals resist group engagement and may devalue or
discount the group.27
FIGURE 9.1 Interpersonal Circumplex
An illustrative example of this type of research may be found in a well-constructed
study that tested the comparative effectiveness of two kinds of group therapy and
attempted to determine the role of clients’ personality traits on the results.28 The
researchers randomly assigned clients seeking treatment for loss and complicated grief (N
= 107) to either a twelve-session interpretive/expressive or a supportive group therapy.
Client outcome assessments included measures of depression, anxiety, self-esteem, and
social adjustment. Before therapy, each client was given the NEO-Five Factor Inventory
(NEO-FFI), which measures five personality variables: neuroticism, extraversion,
openness, conscientiousness, and agreeableness.29 What did the study find?
1. Both group therapies were demonstrably effective, although the interpretive group
generated much greater affect and anxiety among the group members.
2. One personality factor, neuroticism, predicted poorer outcome in both types of
group.
3. Three factors predicted good outcomes with both treatments: extraversion,

conscientiousness, and openness.
4. The fifth factor, agreeableness predicted success in the interpretive/ expressive
group therapy but not in the supportive group therapy.
The authors suggest that the agreeableness factor is particularly important in sustaining
relatedness in the face of the challenging work associated with this form of intensive
group therapy.
Two other personality measures relevant to group therapy outcome have also been
studied in depth: psychological-mindedness30 and the Quality of Object Relations (QOR)
Scale.31w Both of these measures have the drawback of requiring that the client participate
in a 30–60-minute semistructured interview (in contrast to the relative ease of a client self-
report instrument such as the NEO-FFI).
Psychological-mindedness predicts good outcome in all forms of group therapy.
Psychologically minded clients are better able to work in therapy—to explore, reflect, and
understand. Furthermore, such clients are more accountable to themselves and responsible
to comembers.32 Clients with higher QOR scores, which reflect greater maturity in their
relationships, are more likely to achieve positive outcomes in interpretive/expressive,
emotionactivating group therapy. They are more trusting and able to express a broader
range of negative and positive emotions in the group. Clients with low QOR scores are
less able to tolerate this more demanding form of therapy and do better in supportive,
emotion-suppressing group formats.33
Once we identify a key problematic interpersonal area in a client, an interesting
question arises: do we employ a therapy that avoids or addresses that area of
vulnerability? The large NIMH study of time-limited therapy in the treatment of
depression demonstrated that clients do not necessarily do well when matched to the form
of therapy that appears to target their specific problems. For example, clients with greater
interpersonal difficulty did less well in the interpersonal therapy. Why would that be?
The answer is that some interpersonal competence is required to make use of
interpersonal therapy. Clients with greater interpersonal dysfunction tend to do better in
cognitive therapy, which requires less interpersonal skill. Conversely, clients with greater
cognitive distortions tend to achieve better results with interpersonal therapy than with
cognitive therapy. An additional finding of the NIMH study is that perfectionistic clients
tend to do poorly in time-limited therapies, often becoming preoccupied with the looming
end of therapy and their disappointment in what they have accomplished.34
Summary: Group compositional research is still a soft science. Nonetheless, some
practical treatment considerations flow from the research findings. Several key principles
can guide us in composing intensive interactional psychotherapy groups:
• Clients will re-create their typical relational patterns within the microcosm of the
group.
• Personality and attachment variables are more important predictors of in-group
behavior than diagnosis alone.

• Clients require a certain amount of interpersonal competence to make the best use
of interactional group therapy.
• Clients who are rigidly domineering or dismissive will impair the work of the
therapy group.
• Members eager for engagement and willing to take social risks will advance the
group’s work.
• Psychologically minded clients are essential for an effective, interactional therapy
group; with too few such clients, a group will be slow and ineffective.
• Clients who are less trusting, less altruistic, or less cooperative will likely struggle
with interpersonal exploration and feedback and may require more supportive
groups.
• Clients with high neuroticism or perfectionism will likely require a longer course of
therapy to effect meaningful change in symptoms and functioning.
Direct Sampling of Group-Relevant Behavior. The most powerful method of predicting
group behavior is to observe the behavior of an individual who is engaged in a task closely
related to the group therapy situation. 35 In other words, the closer we can approximate the
therapy group in observing individuals, the more accurately we can predict their in-group
behavior. Substantial research evidence supports this thesis. An individual’s behavior will
show a certain consistency over time, even though the people with whom the person
interacts change—as has been demonstrated with therapist-client interaction and small
group interaction.36 For example, it has been demonstrated that a client seen by several
individual therapists in rotation will be consistent in behavior (and, surprisingly, will
change the behavior of each of the therapists!).37
Since we often cannot accurately predict group behavior from an individual interview,
we should consider obtaining data on behavior in a group setting. Indeed, business and
government have long found practical applications for this principle. For example, in
screening applicants for positions that require group-related skills, organizations observe
applicants’ behavior in related group situations. A group interview test has been used to
select Air Force officers, public health officers, and many types of public and business
executives and industry managers. Universities have also made effective use of group
assessment to hire academic faculty.38
This general principle can be refined further: group dynamic research also demonstrates
that behavior in one group is consistent with behavior in previous groups, especially if the
groups are similar in composition,39 in group task,40 in group norms,41 in expected role
behavior,42 or in global group characteristics (such as climate or cohesiveness).43 In other
words, even though one’s behavior is broadly consistent from one group to the next, the
individual’s specific behavior in a new group is influenced by the task and the structural
properties of the group and by the specific interpersonal styles of the other group
members.
The further implication, then, is that we can obtain the most relevant data for prediction

of group behavior by observing an individual behave in a group that is as similar as
possible to the one for which he or she is being considered. How can we best apply this
principle? The most literal application would be to arrange for the applicant to meet with
the therapy group under consideration and to observe his or her behavior in this setting. In
fact, some clinicians have attempted just that: they invite prospective members to visit the
group on a trial basis and then ask the group members to participate in the selection
process.44 Although there are several advantages to this procedure (to be discussed in
chapter 11), I find it clinically unwieldy: it tends to disrupt the group; the members are
disinclined to reject a prospective member unless there is some glaring incompatibility;
furthermore, prospective members may not act naturally when they are on trial.
An interesting research technique with strong clinical implications is the waiting-list
group—a temporary group constituted from a clinic waiting list. Clinicians observe the
behavior of a prospective group therapy member in this group and, on the basis of the data
they obtain there, refer the individual to a specific therapy or research group. In an
exploratory study, researchers formed four groups of fifteen members each from a group
therapy waiting list; the groups met once a week for four to eight weeks.45 Waiting-list
group behavior of the clients not only predicted their behavior in their subsequent long-
term therapy group but also enhanced the clients’ engagement in their subsequent therapy
group. They concluded, as have other researchers using a group diagnostic procedure for
clients applying for treatment, that clients did not react adversely to the waiting-list
group.46 It is challenging to lead waiting list groups. It requires an experienced leader who
has the skill to sustain a viable group in an understaffed setting dealing with vulnerable
and often demoralized clients.47
In one well-designed project, thirty clients on a group therapy waiting list were placed
into four one-hour training sessions. The sessions were all conducted according to a single
protocol, which included an introduction to here-and-now interaction.48 The researchers
found that each client’s verbal participation and interpersonal responsivity in the training
sessions correlated with their subsequent behavior during their first sixteen group therapy
sessions. These findings were subsequently replicated in another, larger project.49

Summary: A number of studies attest to the predictive power of observed pretherapy
group behavior. Furthermore, there is a great deal of corroborating evidence from human
relations and social-psychological group research that subsequent group behavior may be
satisfactorily predicted from pretherapy waiting or training groups.†

The Interpersonal Intake Interview. For practitioners or clinics facing time or resource
pressures, the use of trial groups may be an intriguing but highly impractical idea. A less
accurate but more pragmatic method of obtaining similar data is an interpersonally
oriented interview in which the therapist tests the prospective group client’s ability to deal

with the interpersonal here-and-now reality. Is the client able to comment on the process
of the intake interview or to understand or accept the therapist’s process commentary? For
example, is the client obviously tense but denies it when the therapist asks? Is the client
able and willing to identify the most uncomfortable or pleasant parts of the interview? Or
comment on how he or she wishes to be thought of by the therapist?
Detailed inquiry should be made into the client’s interpersonal and group relationships,
relationships with early chums, closest prolonged friendships, and degree of intimacy with
members of both sexes. Many of Harry Stack Sullivan’s interview techniques are of great
value in this task.50 It is informative, for example, when inquiring about friendships to ask
for the names of best friends and what has become of them. It is valuable to obtain a
detailed history of formal and informal groups, childhood and adult cliques, fraternities,
club memberships, gangs, teams, elected offices, and informal roles and status positions. I
find it valuable to ask the client to give a detailed description of a typical twenty-four
hours and to take particular note of the way the client’s life is peopled.
The predictive power of this type of interview has yet to be determined empirically, but
it seems to me far more relevant to subsequent group behavior than does the traditional
intake clinical interview. This interview approach has become a standard assessment
component in interpersonal therapy (IPT) and cognitive behavioral analysis system
psychotherapy (CBASP).51
Fifty years ago, Powdermaker and Frank described an interpersonal relations interview
that correctly predicted several patterns of subsequent group therapy behavior, such as
“will dominate the group by a flood of speech and advice”; “will have considerable
difficulty in showing feelings but will have compulsion to please the therapist and other
members”; “will be bland and socially skillful, tending to seek the leader’s attention while
ignoring the other members”; “will have a wait-and-see attitude”; or “will have a sarcastic,
superior ‘show-me’ attitude and be reluctant to discuss his problems.”52 Contemporary
psychotherapists have made an important addition to this approach: they emphasize the
client’s beliefs and expectations about relationships, which give form to the client’s
interpersonal behavior. This behavior in turn pulls characteristic responses from others.53
Such a sequence is illustrated in the following vignette, which also illustrates the
necessity of the therapist attending to his own emotional and behavioral reactions and
responses to the client.
• Connie, a woman in her forties, was referred by her family physician for group
therapy because of her social anxiety, dysthymia, and interpersonal isolation.
Immediately on entering the office she told me she had a “bone to pick” with me.
“How could you leave a message on my answering machine calling me Connie
and yourself Doctor So-and-so? Don’t you understand the power imbalance that
perpetuates? Haven’t you heard of feminism and empowerment? Do you treat all
the women you know like this, or only your clients?”
I was at first stunned, and then felt threatened and angry. After a few moments’
reflection I considered that she indeed had a point, and I acknowledged my

carelessness.
Later in the session I asked whether we might explore the extent of her anger,
and we soon began discussing her expectation that she would be silenced and
devalued in this process, as she had been so many times in the past. I told her that
she had, in a sense, presented a powerful test to me—hoping, perhaps, that I would
not take the bait, that I would not confirm her expectations about how her world
always treats her, a pattern that often resulted in her feeling rebuked, attacked, and
shut down. I suggested that she no doubt came to these beliefs honestly and that
they reflected her experiences in life. She may well initially relate to the group
members in the same way that she did with me, but she did have a choice. She
could make the group experience yet another in a series of angry rejections, or she
could begin a process of learning and understanding that could interrupt this self-
fulfilling prophecy.
Summary
Group behavior can be predicted from a pretherapy encounter. Of all the prediction
methods, the traditional intake individual interview oriented toward establishing a
diagnosis appears the least accurate, and yet it is the most commonly used. An
individual’s group behavior will vary depending on internal psychological needs, the
manner of expressing them, the interpersonal composition and the norms of the group. A
general principle, however, is that the more similar the intake procedure is to the actual
group situation, the more accurate will be the prediction of a client’s behavior . The most
promising single clinical method may be observation of a client’s behavior in an intake,
role-play, or waiting-list group. If circumstances and logistics do not permit this method, I
recommend that group therapists modify their intake interview to focus primarily on a
client’s interpersonal functioning.
PRINCIPLES OF GROUP COMPOSITION
To return now to the central question: Given ideal circumstances—a large number of
client applicants, plenty of time, and a wealth of information by which we can predict
behavior—how then to compose the therapy group?
Perhaps the reason for the scarcity of interest in the prediction of group behavior is that
the information available about the next step—group composition—is even more
rudimentary. Why bother refining tools to predict group behavior if we do not know how
to use this information? Although all experienced clinicians sense that the composition of
a group profoundly influences its character, the actual mechanism of influence has eluded
clarification.54 I have had the opportunity to study closely the conception, birth, and
development of more than 250 therapy groups—my own and my students’—and have

been struck repeatedly by the fact that some groups seem to jell immediately, some more
slowly, and other groups founder painfully and either fail entirely or spin off members and
emerge as working groups only after several cycles of attrition and addition of members. It
has been my impression that whether a group jells is only partly related to the competence
or efforts of the therapist or to the number of “good” members in the group. To a degree,
the critical variable is some as yet unclear blending of the members.
A clinical experience many years ago vividly brought this principle home to me. I was
scheduled to lead a six-month experiential group of clinical psychology interns, all at the
same level of training and approximately the same age. At the first meeting, over twenty
participants appeared—too many for one group—and I decided to break them into two
groups, and asked the participants simply to move in random fashion around the room for
five minutes and at the end of that time position themselves at one or the other end of the
room. Thereafter, each group met for an hour and a half, one group immediately following
the other.
Although superficially it might appear that the groups had similar compositions, the
subtle blending of personalities resulted in each having a radically different character. The
difference was apparent in the first meeting and persisted throughout the life of the groups.
One group assumed an extraordinarily dependent posture. In the first meeting, I arrived on
crutches with my leg in a cast because I had injured my knee playing football a couple of
days earlier. Yet the group made no inquiry about my condition. Nor did they themselves
arrange the chairs in a circle. (Remember that all were professional therapists, and most
had led therapy groups!) They asked my permission for such acts as opening the window
and closing the door. Most of the group life was spent analyzing their fear of me, the
distance between me and the members, my aloofness and coldness.
In the other group, I wasn’t halfway through the door before several members asked,
“Hey, what happened to your leg?” The group moved immediately into hard work, and
each of the members used his or her professional skills in a constructive manner. In this
group I often felt unnecessary to the work and occasionally inquired about the members’
disregard of me.
This “tale of two groups” underscores the fact that the composition of the groups
dramatically influenced the character of their subsequent work. If the groups had been
ongoing rather than time limited, the different environments they created might eventually
have made little difference in the beneficial effect each group had on its members. In the
short run, however, the members of the first group felt more tense, more deskilled, and
more restricted. Had it been a therapy group, some members might have felt so
dissatisfied that they would have dropped out of the group. The group was dominated by
what Nitsun describes as “antigroup” forces (elements present in each group that serve to
undermine the group’s work).55 Because of their narrower range of experience in the
group, they learned less about themselves than the members of the other group did.
A similar example may be drawn from two groups in the Lieberman, Yalom, and Miles
group study.56 These two short-term groups were randomly composed but had an identical
leader—a tape recording that provided instructions about how to proceed at each meeting

(the Encountertape Program). Within a few meetings, two very different cultures emerged.
One group was dependably obedient to the taped instructions and faithfully followed all
the prescribed exercises. The other group developed a disrespectful tone to the tape, soon
referring to it as “George.” It was common for these members to mock the tape. For
example, when the tape gave an instruction to the group, one member commented
derisively, “That’s a great idea, George!” Not only was the culture different for these
groups, but so was the outcome. At the end of the thirty-hour group experience—ten
meetings—the irreverent group had an appreciably better outcome.
Thus, we can be certain that composition affects the character and process of the group.
Still, we are a long way from concluding that a given method X composes a group more
effectively than method Y does. Group therapy outcome studies are complex, and rigorous
research has not yet defined the relationship between group composition and the ultimate
criterion: therapy outcome. Despite some promising work using the personality variables
reviewed earlier in this chapter, we still must rely largely on nonsystematic clinical
observations and studies stemming from nontherapy settings.
Clinical Observations
The impressions of individual clinicians on the effects of group composition must be
evaluated with caution. The lack of a common language for describing behavior, the
problems of outcome evaluation, the theoretical biases of the therapist, and the limited
number of groups that any one clinician may treat all limit the validity of clinical
impressions in this area.
There appears to be a general clinical sentiment that heterogeneous groups have
advantages over homogeneous groups for long-term intensive interactional group
therapy.†57 Homogeneous groups, on the other hand, have many advantages if the
therapist wishes to offer support for a shared problem or help clients develop skills to
obtain symptomatic relief over a brief period.58 Even with these groups, however,
composition is not irrelevant. A homogeneous group for men with HIV or women with
breast cancer will be strongly affected by the stage of illness of the members. An
individual with advanced disease may represent the other members’ greatest fears and lead
to members’ disengagement or withdrawal.59
Even in highly specialized, homogeneous, manual-guided group therapies, such as
groups for individuals dealing with a genetic predisposition to developing breast or
colorectal cancer, the therapist can expect composition to play a substantial role.60 Like
the group of psychology interns described earlier, some therapy groups quickly come
together, whereas others stumble along slowly, even with the same leader.
In general, though, homogeneous groups jell more quickly, become more cohesive, offer
more immediate support to group members, are better attended, have less conflict, and
provide more rapid relief of symptoms . However, many clinicians believe that they do not
lend themselves to long-term psychotherapeutic work with ambitious goals of personality

change. The homogeneous group, in contrast to the heterogeneous group, has a tendency
to remain at superficial levels and is a less effective medium for the altering of character
structure.
The issue becomes clouded when we ask, “Homogeneous for what?” “Heterogeneous
for what?” “For age?” “Sex?” “Symptom complex?” “Marital status?” “Education?”
“Socioeconomic status?” “Verbal skills?” “Psychosexual development?” “Psychiatric
diagnostic categories?” “Interpersonal needs?” Which of these are the critical variables? Is
a group composed of women with bulimia or seniors with depression homogeneous
because of the shared symptom, or heterogeneous because of the wide range of personality
traits of the members?
A number of authors seek to clarify the issue by suggesting that the group therapist
strive for maximum heterogeneity in the clients’ conflict areas and patterns of coping, and
at the same time strive for homogeneity of the clients’ degree of vulnerability and capacity
to tolerate anxiety. For example, a homogeneous group of individuals who all have major
conflicts about hostility that they dealt with through denial could hardly offer therapeutic
benefit to its members. However, a group with a very wide range of vulnerability (loosely
defined as ego strength) will, for different reasons, also be retarded: the most vulnerable
member will place limits on the group, which will become highly restrictive to the less
vulnerable ones. Foulkes and Anthony suggest blending diagnoses and disturbances to
form a therapeutically effective group. The greater the span between the polar types, the
higher the therapeutic potential.61 But the head and tail of the group both must stay
connected to the body of the group for therapeutic benefit to emerge.
Unfolding from these clinical observations is the rule that a degree of incompatibility
must exist between the client and the interpersonal culture of the group if change is to
occur. This principle—that change is preceded by a state of dissonance or incongruity—is
backed by considerable clinical and social-psychological research; I will return to it later
in this chapter. In the absence of adequate ego strength, however, group members cannot
profit from the dissonance.
Therefore, for the long-term intensive therapy group, the rule that will serve clinicians
in good stead is: heterogeneity for conflict areas and homogeneity for ego strength. We
seek heterogeneity of individuals with regard to gender, level of activity or passivity,
thinking and feeling, and interpersonal difficulties, but homogeneity with regard to
intelligence, capacity to tolerate anxiety, and ability to give and receive feedback and to
engage in the therapeutic process.
But heterogeneity must not be maintained at the price of creating a group isolate.
Consider the age variable: If there is one sixty-year-old member in a group of young
adults, that individual may choose (or be forced) to personify the older generation. Thus,
this member is stereotyped (as are the younger members), and the required interpersonal
honesty and intimacy will fail to materialize. A similar process may occur in an adult
group with a lone late adolescent who assumes the unruly teenager role. Yet there are
advantages to having a wide age spread in a group. Most of my ambulatory groups have
members ranging in age from twenty-five to sixty-five. Through working out their

relationships with other members, they come to understand their past, present, and future
relationships with a wider range of significant people: parents, peers, and children.
Sexual orientation, cultural, and ethno-racial factors similarly need to be considered.
Group members from minority backgrounds will need to trust that other group members
are willing to consider each individual’s specific context and not to view that individual as
a stereotype of his culture.†
Some therapists employ another concept—role heterogeneity—in their approach to
group composition. Their primary consideration when adding a new member is what role
in the group is open. Theoretically, such an orientation seems desirable. Practically,
however, it suffers from lack of clarity. An extraordinary range of therapy group roles
have been suggested: task leader, social-emotional leader, provocateur, doctor’s helper,
help-rejecting complainer, self-righteous moralist, star, fight/flight leader, dependency
leader, pairing leader, group hysteric, technical executive leader, social secretary, group
stud, group critic, group romantic, guardian of democracy, timekeeper, aggressive male,
vigilante of honesty, the sociable role, the structural role, the divergent role, the cautionary
role, the scrutinizer, the innocent, the scapegoat, the intellectualizer, the child, the puritan,
the reintegrater, and so on. Can we expand the list arbitrarily and indefinitely by including
all behavior trait constellations? Or is there a fixed set of roles, constant from group to
group, that members are forced to fill? Until we have some satisfactory frame of reference
to deal with these questions, asking “What role is open in the group?” will contribute little
toward an effective approach to group composition.
Clinical experience demonstrates that groups do better if some members can be
exemplars and advocates of constructive group norms. Placing one or two “veterans” of
group therapy into a new group may pay large dividends. Conversely, we can sometimes
predict that clients will fit poorly with a particular group because of the likelihood that
they will assume an unhealthy role in it. Consider this clinical illustration:
• Eve, a twenty-nine-year-old woman with prominent narcissistic personality
difficulties, was evaluated for group therapy. She was professionally successful but
interpersonally isolated, and she experienced chronic dysthymia that was only
partially ameliorated with antidepressants. When she came to my office for a
pregroup consultation, within minutes I experienced her as brittle, explosive,
highly demanding, and devaluing of others. In many ways, Eve’s difficulties echoed
those of another woman, Lisa, who had just quit this group (thereby creating the
opening for which Eve was being evaluated). Lisa’s intense, domineering need to
be at the center of the group, coupled with an exquisite vulnerability to feedback,
had paralyzed the group members, and her departure had been met with clear
relief by all. At another time, this group and Eve could have been a constructive fit.
So soon after Lisa’s departure, however, it was very likely that Eve’s characteristic
style of relating would trigger strong feelings in the group of “here we go again,”
shifting the group members back into feelings that they had just painfully
processed. An alternative group for Eve was recommended.
One final clinical observation. As a supervisor and researcher, I had an opportunity to

study closely the entire thirty-month course of an ambulatory group led by two competent
psychiatric residents. The group consisted of seven members, all in their twenties, six of
whom could be classified as having schizoid personality disorder. The most striking
feature of this homogeneous group was its extraordinary dullness. Everything associated
with the group meetings, tape recordings, written summaries, and supervisory sessions
seemed low-keyed and plodding. Often nothing seemed to be happening: there was no
discernible movement individually among the members or in the group as a whole. And
yet attendance was near perfect, and the group cohesiveness extraordinarily high.
At that time many ambulatory groups in the Stanford outpatient clinic were part of a
study involving the measurement of group cohesiveness. This homogeneous schizoid
group scored higher on cohesiveness (measured by self-administered questionnaires) than
any other group. Since all the group participants in the Stanford clinic during this period
were subjects in outcome research,62 thorough evaluations of clinical progress were
available at the end of one year and again at thirty months. The members of this group,
both the original members and the replacements, did extraordinarily well and underwent
substantial characterological changes as well as complete symptomatic remission. In fact,
few other groups I’ve studied have had comparably good results. My views about group
composition were influenced by this group, and I have come to attach great importance to
group stability, attendance, and cohesiveness.
Although in theory I agree with the concept of composing a group of individuals with
varied interpersonal stresses and needs, I feel that in practice it may be a spurious issue.
Given the limited predictive value of our traditional screening interview, it is probable that
our expectations exceed our abilities if we think we can achieve the type of subtle balance
and personality interlocking necessary to make a real difference in group functioning. For
example, although six of the seven members in the group I just discussed were diagnosed
as schizoid personalities, they differed far more than they resembled one another. This
apparently homogeneous group, contrary to the clinical dictum, did not remain at a
superficial level and effected significant personality changes in its members. Although the
interaction seemed plodding to the therapists and researchers, it did not to the participants.
None of them had ever had intimate relationships, and many of their disclosures, though
objectively unremarkable, were subjectively exciting first-time disclosures.
Many so-called homogeneous groups remain superficial, not because of homogeneity
but because of the psychological set of the group leaders and the restricted group culture
they fashion. Therapists who organize a group of individuals around a common symptom
or life situation must be careful not to convey powerful implicit messages that generate
group norms of restriction, a search for similarities, submergence of individuality, and
discouragement of self-disclosure and interpersonal honesty. Norms, as I elaborated in
chapter 5, once set into motion, may become self-perpetuating and difficult to change. We
should aim to reduce negative outcomes by forming groups with members who offer care,
support, mutual engagement, regular attendance, and openness, but composition itself is
not always destiny.†
What about gender and group composition? Some authors, arguing from theory or

clinical experience, advocate single-gender groups, but the limited empirical research does
not support this.63 Men in all-male groups are less intimate and more competitive, whereas
men in mixed-gender groups are more self-disclosing and less aggressive. Unfortunately,
the benefit of gender heterogeneity does not accrue to the women in these groups: women
in mixed-gender groups may become less active and deferential to the male participants.
Men may do poorly in mixed-gender groups composed of only one or two men and
several women; men in this instance may feel peripheral, marginalized, and isolated.64
OVERVIEW
It would be most gratifying at this point to integrate these clinical and experimental
findings, to point out hitherto unseen lines of cleavage and coalescence, and to emerge
with a crisp theory of group composition that has firm experimental foundations as well as
immediate practicality. Unfortunately, the data do not permit such a definitive synthesis.
But there is value in highlighting major research findings that pertain to group
composition.
The culture and functioning of every group—its ethos, values, and modus vivendi—will
be influenced by the composition of its members. Our approach to composition must be
informed by our understanding of the group’s tasks. The group must be able to respond to
members’ needs for emotional support and for constructive challenge. In psychotherapy
groups we should aim for a composition that balances similarity and divergence in
interpersonal engagement and behavior; relationship to authority; emotional bonding; and
task focus. Moreover, it is essential that members agree with the values that guide the
therapeutic enterprise.
The research also points to certain unequivocal findings. The composition of a group
does make a difference and influences many aspects of group function.† A group’s
composition influences certain predictable short-term characteristics—for example, high
cohesion and engagement, high conflict, high flight, high dependency. Furthermore, we
can, if we choose to use available procedures, predict to some degree the group behavior
of the individual.
What we are uncertain of, however, is the relationship between any of these group
characteristics and the ultimate therapy outcome of the group members. Furthermore, we
do not know how much the group leader may alter these characteristics of the group or
how long an ongoing group will manifest them. We do know, however, that cohesive
groups with higher engagement generally produce better clinical outcomes.†
In practice there are two major theoretical approaches to group composition: the
homogeneous and the heterogeneous approach. Let us examine briefly the theoretical
underpinnings of these two approaches. Underlying the heterogeneous approach to
composition are two theoretical rationales that may be labeled the social microcosm
theory and the dissonance theory. Underlying the homogeneous group composition

approach is the group cohesiveness theory.
The Heterogeneous Mode of Composition
The social microcosm theory postulates that because the group is regarded as a miniature
social universe in which members are urged to develop new methods of interpersonal
interaction, the group should be heterogeneous in order to maximize learning
opportunities. It should resemble the real social universe by being composed of
individuals of different sexes, professions, ages, and socioeconomic and educational
levels. In other words, it should be a demographic assortment.
The dissonance theory as applied to group therapy also suggests a heterogeneous
compositional approach, but for a different reason. Learning or change is likely to occur
when the individual, in a state of dissonance, acts to reduce that dissonance. Dissonance
creates a state of psychological discomfort and propels the individual to attempt to achieve
a more consonant state. Individuals who find themselves in a group in which membership
has many desirable features (for example, hopes of alleviation of suffering, attraction to
the leader and other members) but which, at the same time, makes tension-producing
demands (for example, self-disclosure or interpersonal confrontation) will experience a
state of dissonance or imbalance.65
Similarly, a state of discomfort occurs when, in a valued group, one finds that one’s
interpersonal needs are unfulfilled or when one’s customary style of interpersonal
behavior produces discord. The individual in these circumstances will search for ways to
reduce discomfort—for example, by leaving the group or, preferably, by beginning to
experiment with new forms of behavior. To facilitate the development of adaptive
discomfort, the heterogeneous argument suggests that clients be exposed to other
individuals in the group who will not reinforce neurotic positions by fulfilling
interpersonal needs but instead will be frustrating and challenging, making clients aware
of different conflict areas and also demonstrating alternative interpersonal modes.
Therefore, it is argued, a group should include members with varying interpersonal
styles and conflicts. It is a delicate balance, because if frustration and challenge are too
great, and the staying forces (the attraction to the group) too small, no real asymmetry or
dissonance occurs; the individual does not change but instead physically or
psychologically leaves the group. If, on the other hand, the challenge is too small, no
learning occurs; members will collude, and exploration will be inhibited. The dissonance
theory thus argues for a broad personality assortment.
The Homogeneous Mode of Composition
The cohesiveness theory, underlying the homogeneous approach to group composition,
postulates, quite simply, that attraction to the group is the intervening variable critical to
outcome and that the paramount aim should be to assemble a cohesive, compatible group.

Summary
How can we reconcile or decide between these two approaches? First, note that no group
therapy research supports the dissonance model. There is great clinical consensus (my
own included) that group therapy clients should be exposed to a variety of conflict areas,
coping methods, and conflicting interpersonal styles, and that conflict in general is
essential to the therapeutic process. However, there is no empirical evidence that
deliberately composed heterogeneous groups facilitate therapy, and I have just cited
modest evidence to the contrary.
On the other hand, a large body of small-group research supports the cohesiveness
concept. Interpersonally compatible therapy groups will develop greater cohesiveness.
Members of cohesive groups have better attendance, are more able to express and tolerate
hostility, are more apt to attempt to influence others, and are themselves more readily
influenced. Members with greater attraction to their group have better therapeutic
outcome; members who are less compatible with the other members tend to drop out of the
group. Members with the greatest interpersonal compatibility become the most popular
group members, and group popularity is highly correlated with successful outcome.
The fear that a homogeneous group will be unproductive, constricted, or conflict free or
that it will deal with a only narrow range of interpersonal concerns is unfounded, for
several reasons. First, there are few individuals whose pathology is indeed monolithic—
that is, who, despite their chief conflict area, do not also encounter conflicts in intimacy or
authority, for example. Second, the group developmental process may demand that clients
deal with certain conflict areas. For example, the laws of group development (see chapter
11) demand that the group ultimately deal with issues of control, authority, and the
hierarchy of dominance. In a group with several controlconflicted individuals, this phase
may appear early or very sharply. In a group lacking such individuals, other members
who are less conflicted or whose conflicts are less overt in the area of dependency and
authority may be forced nonetheless to deal with it as the group inevitably moves into this
stage of development. If certain developmentally required roles are not filled in the group,
most leaders, consciously or unconsciously, alter their behavior to fill the void.66
Furthermore—and this is an important point—no therapy group with proper leadership
can be too comfortable or fail to provide dissonance for its members, because the
members must invariably clash with the group task. To develop trust, to disclose oneself,
to develop intimacy, to examine oneself, to confront others—are all discordant tasks to
individuals who have significant problems in interpersonal relationships.
Many problem-specific brief groups can easily be transformed into a productive
interactional group with proper guidance from the leader. For example, two rigorous
studies compared homogeneous groups of clients with bulimia who were randomly
assigned to behavioral group therapy, cognitive-behavioral group therapy, or
interactional group therapy (therapy that did not explicitly address eating behavior but
instead focused entirely on interpersonal interaction). Not only did these homogeneous
interactional groups function effectively, but their outcome was in every way equal to the

cognitive-behavioral groups, including their positive effect on the eating disorder.67
On the basis of our current knowledge, therefore, I propose that cohesiveness be the
primary guideline in the composition of therapy groups. The hoped-for dissonance will
unfold in the group, provided the therapist functions effectively in the pretherapy
orientation of clients and during the early group meetings. Group integrity should be
given highest priority, and group therapists must select clients with the lowest likelihood
of premature termination. Individuals with a high likelihood of being irreconcilably
incompatible with the prevailing group ethos and culture, or with at least one other
member, should not be included in the group. It bears repeating that group cohesiveness is
not synonymous with group comfort or ease. Quite the contrary: it is only in a cohesive
group that conflict can be tolerated and transformed into productive work.
A FINAL CAVEAT
Admittedly, the idea of crafting an ideal group is seductive. It is a siren’s wail that has
lured many researchers and generated a large body of research, little of which, alas, has
proved substantial, replicable, or clinically relevant. Not only that, but, in many ways, the
topic of group composition is out of touch with the current everyday realities of clinical
practice. As noted earlier, contemporary pressures on the practice of group therapy
discourage the therapist’s attention to group composition as a relevant concern.
Many contemporary group clinicians in private practice and in public clinics are more
concerned with group integrity and survival. Generally, these clinicians have difficulty
accumulating enough clients to form and maintain groups. (And I have no doubt that this
difficulty will grow with each passing year because of the rapid increase in numbers of
practicing psychotherapists from ever more professional disciplines.) The more therapists
available, the more professional competition for clients, the harder it is to begin and
maintain therapy groups in private practice. Therapists prefer to fill their individual hours
and are reluctant to risk losing a client through referral to a therapy group. If clinicians
attempt to put some group candidates on hold while awaiting the perfect blend of group
participants—assuming that we know the formula of the blend (which we do not)—they
will never form a group. Referrals accumulate so slowly that the first prospective
members interviewed may tire of waiting and find suitable therapy elsewhere.
Thus contemporary clinicians, myself included, generally form groups by accepting,
within limits, the first suitable seven or eight candidates screened and deemed to be good
group therapy candidates. Only the crudest principles of group composition are employed,
such as having an equal number of men and women or a wide range of age, activity, or
interactional style. For example, if two males already selected for the group are
particularly passive, it is desirable to create balance by adding more active men.
Other excellent options exist in practice, however. First, the clinician may compose a
group from clients in his individual practice. As I shall discuss in chapter 15, concurrent

therapy is a highly effective format. Second, clinicians who are in a collaborative practice,
often sharing a suite of offices, may coordinate referrals and fill one group at a time. In
many communities, group therapists have successfully created a specialty practice by
marketing themselves through speaking engagements and advertising.
The therapist’s paramount task is to create a group that coheres. Time and energy spent
on delicately casting and balancing a group cannot be justified, given the current state of
our knowledge and clinical practice. I believe that therapists do better to invest their time
and energy in careful selection of clients for group therapy and in pretherapy preparation
(to be discussed in the next chapter). There is no question that composition radically
affects the group’s character, but if the group holds together and if you appreciate the
therapeutic factors and are flexible in your role, you can make therapeutic use of any
conditions (other than lack of motivation) that arise in the group.

Chapter 10
CREATION OF THE GROUP: PLACE, TIME, SIZE,
PREPARATION
PRELIMINARY CONSIDERATIONS
Before convening a group, therapists must secure an appropriate meeting place and make
a number of practical decisions about the structure of the therapy: namely, the size and the
life span of the group, the admission of new members, the frequency of meetings, and the
duration of each session. In addition, the contemporary practitioner often must negotiate a
relationship with a third-party payer, HMO, or managed care organization. 1 The tension
between therapeutic priorities and the economic priorities of managed care regarding the
scope and duration of treatment must also be addressed.2 Dissonance between therapists
and third-party administrators may have a deleterious impact on the client-therapist
relationship. † The entire practice of therapy, including therapists’ morale, will benefit
from greater partnership and less polarization.
Today clinicians have an ethical responsibility to advocate for effective therapy. They
must educate the public, destigmatize group therapy, build strong clinical practice
organizations with well-trained and properly credentialed clinicians, and urge third-party
payers to attend to the robust empirical research supporting group therapy’s
effectiveness.†
The Physical Setting
Group meetings may be held in any room that affords privacy and freedom from
distractions. In institutional settings, the therapist must negotiate with the administration to
establish inviolate time and space for therapy groups. The first step of a meeting is to form
a circle so that members can all see one another. For that reason, a seating arrangement
around a long, rectangular table or the use of sofas that seat three or four people is
unsatisfactory. If members are absent, most therapists prefer to remove the empty chairs
and form a tighter circle.
If the group session is to be videotaped or observed through a one-way mirror by
trainees, the group members’ permission must be obtained in advance and ample
opportunity provided for discussion of the procedure. Written consent is essential if any
audiovisual recording is planned. A group that is observed usually seems to forget about
the viewing window after a few weeks, but often when working through authority issues
with the leader, members again become concerned about it. If only one or two students are

regular observers, it is best to seat them in the room but outside of the group circle. This
avoids the intrusion of the mirror and allows the students to sample more of the group
affect, which inexplicably is often filtered out by the mirror. Observers should be
cautioned to remain silent and to resist any attempts of the group members to engage them
in the discussion. (See chapter 17 for further discussion about group observation.)
Open and Closed Groups
At its inception, a group is designated by its leader as open or closed. A closed group,
once begun, shuts its gates, accepts no new members except within the first 2 or 3 sessions
and meets for a predetermined length of time. An open group, by contrast, maintains a
consistent size by replacing members as they leave the group. An open group may have a
predetermined life span—for example, groups in a university student health service may
plan to meet only for the nine-month academic year. Many open groups continue
indefinitely even though every couple of years there may be a complete turnover of group
membership and even of leadership. I have known of therapy groups in psychotherapy
training centers that have endured for twenty years, being bequeathed every year or two by
a graduating therapist to an incoming student. Open groups tolerate changes in
membership better if there is some consistency in leadership. One way to achieve this in
the training setting is for the group to have two co-therapists; when the senior co-therapist
leaves, the other one continues as senior group leader, and a new co-therapist joins.3
Most closed groups are brief therapy groups that meet weekly for six months or less. A
longer closed group may have difficulty maintaining stability of membership. Invariably,
members drop out, move away, or face some unexpected scheduling incompatibility.
Groups do not function well if they become too small, and new members must be added
lest the group perish from attrition. A long-term closed-group format is feasible in a
setting that assures considerable stability, such as a prison, a military base, a long-term
psychiatric hospital, and occasionally an ambulatory group in which all members are
concurrently in individual psychotherapy with the group leader. Some therapists lead a
closed group for six months, at which time members evaluate their progress and decide
whether to commit themselves to another six months.
Some intensive partial hospitalization programs begin with an intensive phase with
closed group therapy, which is followed by an extended, less intensive open group therapy
aftercare maintenance phase. The closed phase emphasizes common concerns and
fundamental skills that are best acquired if the whole group can move in concert. The open
phase, which aims to reduce relapse, reinforces the gains made during the intensive phase
and helps clients apply their gains more broadly in their own social environments. This
model has worked well in the treatment of substance abuse, trauma, and depression.4
DURATION AND FREQUENCY OF MEETINGS

Until the mid-1960s, the length of a psychotherapy session seemed fixed: the fifty-minute
individual hour and the eighty- to ninety-minute group therapy session were part of the
entrenched wisdom of the field. Most group therapists agree that, even in well-established
groups, at least sixty minutes is required for the warm-up interval and for the unfolding
and working through of the major themes of the session. There is also some consensus
among therapists that after about two hours, the session reaches a point of diminishing
returns: the group becomes weary, repetitious, and inefficient. Many therapists appear to
function best in segments of eighty to ninety minutes; with longer sessions therapists often
become fatigued, which renders them less effective in subsequent therapy sessions on the
same day.
Although the frequency of meetings varies from one to five times a week, the
overwhelming majority of groups meet once weekly. It is often logistically difficult to
schedule multiple weekly ambulatory group meetings, and most therapists have never led
an outpatient group that meets more than once a week. But if I had my choice, I would
meet with groups twice weekly: such groups have a greater intensity, the members
continue to work through issues raised in the previous session, and the entire process takes
on the character of a continuous meeting. Some therapists meet twice weekly for two or
three weeks at the start of a time-limited group to turbocharge the intensity and launch the
group more effectively.5
Avoid meeting too infrequently. Groups that meet less than once weekly generally have
considerable difficulty maintaining an interactional focus. If a great deal has occurred
between meetings in the lives of the members, such groups have a tendency to focus on
life events and on crisis resolution.
The Time-Extended Group. In efforts to achieve “time-efficient therapy,” 6 group leaders
have experimented with many aspects of the frame of therapy, but none more than the
duration of the meeting. Today’s economically driven climate pressures therapists to
abbreviate therapy, but the opposite was true in the 1960s and 1970s, the heyday of the
encounter groups (see chapter 16), when group therapists experimented boldly with the
length of meetings. Therapists held weekly meetings that lasted four, six, even eight hours.
Some therapists chose to meet less frequently but for longer periods—for example, a six-
hour meeting every other week. Individual therapists often referred their clients to a
weekend time-extended group. Some group therapists referred their entire group for a
weekend with another therapist or, more commonly, conducted a marathon meeting with
their own group sometime during the course of therapy.
The “marathon group” was widely publicized during that time in U.S. magazines,
newspapers, and fictionalized accounts.† It met for a prolonged session, perhaps lasting
twenty-four or even forty-eight hours, with little or no time permitted for sleep.
Participants were required to remain together for the entire designated time. Meals were
served in the therapy room, and sleep, if needed, was snatched during quick naps in the
session or in short scheduled sleep breaks. The emphasis of the group was on total self-
disclosure, intensive interpersonal confrontation, and affective involvement and
participation. Later the time-extended format was adapted by such commercial enterprises

as est and Lifespring; today, these large group awareness training programs have virtually
disappeared.7
Proponents of the time-extended group claimed that it accelerated group development,
intensified the emotional experience, and efficiently condensed a lengthy course of
therapy into a day or a weekend.† The emotional intensity and fatigue resulting from lack
of sleep was also thought to accelerate the abandonment of social facades. The results of
marathon group therapy reported in the mass media and in scientific journals at the time
were mind-boggling, exceeding even today’s claims of the personality-transforming
effects of new miracle drugs: “Eighty percent of the participants undergo significant
change as the result of a single meeting”; 8 “ninety percent of 400 marathon group
members considered the meeting as one of the most significant and meaningful
experiences of their lives”;9 “marathon group therapy represents a breakthrough in
psychotherapeutic practice”;10 “the marathon group has become a singular agent of
change which allows rapidity of learning and adaptation to new patterns of behavior not
likely to occur under traditional arrangements”; 11 “if all adults had been in a marathon,
there would be no more war; if all teenagers had been in a marathon, there would be no
more juvenile delinquency”;12 and so on.
Yet despite these claims, the marathon movement has come and gone. The therapists
who still regularly or periodically hold time-extended group meetings represent a small
minority of practitioners. Though there have been occasional recent reports of intensive,
and effective, retreat weekends for various conditions ranging from substance abuse to
bulimia, 13 these enterprises consist of a comprehensive program that includes group
therapy, psychoeducation, and clear theory rather than a reliance on the intensive
confrontation and fatigue characteristic of the marathon approach. This approach is also
used today to augment weekly group therapy for clients with cancer, in the form of an
intensive weekend retreat for skill building, reflection, and meditation.14
Nonetheless, it is important to inform ourselves about the marathon movement—not
because it has much current usage, nor to pay homage to it as a chapter in the history of
psychotherapy, but because of what it reveals about how therapists make decisions about
clinical practice. Over the past several decades, psychotherapy in general and group
therapy in particular have been taken by storm by a series of ideological and stylistic fads.
Reliance on the fundamentals and on well-constructed research is the best bulwark against
will-o’-the-wisp modes of therapy dominated by the fashion of the day.
Many therapeutic fads come and go so quickly that research rarely addresses the issues
they raise. Not so for the time-extended meeting, which has spawned a considerable
research literature. Why? For one thing, the format lends itself to experimentation: it is far
easier to do outcome research on a group that lasts, say, one day than on one that lasts for
six months: there are fewer dropouts, fewer life crises, no opportunities for subjects to
obtain ancillary therapy. Another reason is that time-extended groups arose in an
organization (the National Training Laboratories—see chapter 16) that had a long tradition
of coupling innovation and research.

The highly extravagant claims I quoted above were based entirely on anecdotal reports
of various participants or on questionnaires distributed shortly after the end of a meeting—
an exceedingly unreliable approach to evaluation. In fact, any outcome study based solely
on interviews, testimonials, or client self-administered questionnaires obtained at the end
of the group is of questionable value. At no other time is the client more loyal, more
grateful, and less objective about a group than at termination, when there is a powerful
tendency to recall and to express only positive, tender feelings. Experiencing and
expressing negative feelings about the group at this point would be unlikely for at least
two reasons: (1) there is strong group pressure at termination to participate in positive
testimonials—few group participants, as Asch15 has shown, can maintain their objectivity
in the face of apparent group unanimity; and (2) members reject critical feelings toward
the group at this time to avoid a state of cognitive dissonance: in other words, once an
individual invests considerable emotion and time in a group and develops strong positive
feelings toward other members, it becomes difficult to question the value or activities of
the group. To do so thrusts the individual into a state of uncomfortable dissonance.
Research on marathon groups is plagued with a multitude of design defects. 16 Some
studies failed to employ proper controls (for example, a non–time-extended comparison
group). Others failed to sort out the effects of artifact and other confounding variables. For
example, in a residential community of drug addicts, an annual marathon group was
offered to rape survivors. Because the group was offered only once a year, the participants
imbued it with value even before it took place.17
The rigorous controlled studies comparing differences in outcome between time-
extended and non–time-extended groups conclude that there is no evidence for the
efficacy of the time-extended format. The positive results reported in a few studies were
unsystematic and evaporated quickly.18
Is it possible, as is sometimes claimed, that a time-extended meeting accelerates the
maturation of a therapy group, that it increases openness, intimacy, and cohesiveness and
thus facilitates insight and therapeutic breakthroughs? My colleagues and I studied the
effect of a six-hour meeting on the development of cohesiveness and of a here-and-now,
interactive communicational mode.19 We followed six newly formed groups in an
ambulatory mental health program for the first sixteen sessions. Three of the groups held a
six-hour first session, whereas the other three held a six-hour eleventh session.20
We found that the marathon session did not favorably influence the communication
patterns in subsequent meetings.21 In fact, there was a trend in the opposite direction: after
the six-hour meetings, the groups appeared to engage in less here-and-now interaction.
The influence of the six-hour meeting on cohesiveness was quite interesting. In the three
groups that held a six-hour initial meeting, there was a trend toward decreased
cohesiveness in subsequent meetings. In the three groups that held a six-hour eleventh
meeting, however, there was a significant increase in cohesiveness in subsequent
meetings. Thus, timing is a consideration: it is entirely possible that, at a particular
juncture in the course of a group, a time-extended session may help increase member
involvement in the group. Hence, the results showed that cohesiveness can be accelerated

but not brought into being by time-extended meetings.
During the 1960s and 1970s, many therapists referred individual therapy patients to
weekend marathon groups; in the 1980s, many sent patients to intensive large-group
awareness training weekends (for example, est and Lifespring). Is it possible that an
intensive, affect-laden time-extended group may open up a client who is stuck in therapy?
My colleagues and I studied thirty-three such clients referred by individual therapists for a
weekend encounter group. We assigned them to one of three groups: two affect-evoking
gestalt marathons and a control group (a weekend of meditation, silence, and tai chi).22
Six weeks later, the experimental subjects showed slight but significant improvement in
their individual therapy compared to the control subjects. By twelve weeks, however, all
differences had disappeared, and there were no remaining measurable effects on the
process of individual therapy.
The marathon group phenomenon makes us mindful of the issue of transfer of learning.
There is no question that the time-extended group can evoke powerful affect and can
encourage members to experiment with new behavior. But does a change in one’s
behavior in the group invariably beget a change in one’s outside life? Clinicians have long
known that change in the therapy session is not tantamount to therapeutic success, that
change, if it is to be consolidated, must be carried over into important outside
interpersonal relationships and endeavors and tested again and again in these natural
settings. Of course therapists wish to accelerate the process of change, but the evidence
suggests that the duration of treatment is more influential than the number of treatments.
The transfer of learning is laborious and demands a certain irreducible amount of time.23
Consider, for example, a male client who, because of his early experience with an
authoritarian, distant, and harsh father, tends to see all other males, especially those in a
position of authority, as having similar qualities. In the group he may have an entirely
different emotional experience with a male therapist and perhaps with some of the male
members. What has he learned? Well, for one thing he has learned that not all men are
frightening bastards—at least there are one or two who are not. Of what lasting value is
this experience to him? Probably very little unless he can generalize the experience to
future situations. As a result of the group, the individual learns that at least some men in
positions of authority can be trusted. But which ones? He must learn how to differentiate
among people so as not to perceive all men in a predetermined manner. A new repertoire
of perceptual skills is needed. Once he is able to make the necessary discriminations, he
must learn how to go about forming relationships on an egalitarian, distortion-free basis.
For the individual whose interpersonal relationships have been impoverished and
maladaptive, these are formidable and lengthy tasks that often require the continual testing
and reinforcement available in the long-term therapeutic relationship.
BRIEF GROUP THERAPY

Brief group therapy is rapidly becoming an important and widely used therapy format. To
a great extent, the search for briefer forms of group therapy is fueled by economic
pressures. Managed care plans and HMOs strive relentlessly for briefer, less expensive,
and more efficient forms of therapy.x A survey of managed care administrators responsible
for the health care of over 73 million participants24 noted that they were interested in the
use of more groups but favored brief, problem-homogeneous, and structured groups. In the
same survey, a range of therapists favored process, interpersonal, and psychodynamic
group therapy without arbitrary time restrictions. Other factors also favor brief therapy: for
example, many geographic locations have high service demands and low availability of
mental health professionals; here, brevity translates into greater access to services.
How long is “brief”? The range is wide: some clinicians say that fewer than twenty to
twenty-five visits is brief,25 others sixteen to twenty sessions, 26 and still others fifty or
sixty meetings.27 Inpatient groups may be thought of as having a life span of a single
session (see chapter 15). Perhaps it is best to offer a functional rather than a temporal
definition: a brief group is the shortest group life span that can achieve some specified
goal—hence the felicitous term “time-efficient group therapy”.28 A group dealing with an
acute life crisis, such as a job loss, might last four to eight sessions, whereas a group
addressing major relationship loss, such as divorce or bereavement, might last twelve to
twenty sessions. A group for dealing with a specific symptom complex, such as eating
disorders or the impact of sexual abuse, might last eighteen to twenty-four sessions. A
“brief” group with the goal of changing enduring characterological problems might last
sixty to seventy sessions.29
These time frames are somewhat arbitrary, but recent explorations into the “dose-effect”
of individual psychotherapy shed some light on the question of duration of therapy.30 This
research attempts to apply the drug dose-response curve model to individual
psychotherapy by studying large numbers of clients seeking psychotherapy in ambulatory
settings. Typically the form of therapy provided is eclectic, integrating supportive,
exploratory, and cognitive therapy approaches without the use of therapy manuals.
Although no comparable dose-effect research in group therapy has been reported, it seems
reasonable to assume that there are similar patterns of response to group therapy.
Researchers note that clients with less disturbance generally require fewer therapy hours
to achieve a significant improvement. Remoralization can occur quickly, and eight
sessions or fewer are sufficient to return many clients to their precrisis level. The vast
majority of clients with more chronic difficulties require about fifty to sixty sessions to
improve, and those with significant personality disturbances require even more. The
greater the impairment in trust or emotional deprivation and the earlier in development the
individual has suffered loss or trauma, the greater the likelihood that a brief therapy will
be insufficient. Failure of prior brief therapies is also often a sign of the need for a longer
therapy.31
Whatever the precise length of therapy, all brief psychotherapy groups (excluding
psychoeducational groups) share many common features. They all strive for efficiency;

they contract for a discrete set of goals and attempt to stay focused on goal attainment;
they tend to stay in the present (with either a here-and-now focus or a “there-and-now”
recent-problem-oriented focus); they attend throughout to the temporal restrictions and the
approaching ending of therapy; they emphasize the transfer of skills and learning from the
group to the real world; their composition is often homogeneous for some problem,
symptomatic syndrome, or life experience; they focus more on interpersonal than on
intrapersonal concerns.32
A course of brief group therapy need not be viewed as the definitive treatment. Instead
it could be considered an installment of treatment—an opportunity to do a piece of
important, meaningful work, which may or may not require another installment in the
future.33
When leading a brief therapy group, a group therapist must heed some general
principles:
• The brief group is not a truncated long-term group;34 group leaders must have a
different mental set: they must clarify goals, focus the group, manage time, and be
active and efficient. Since groups tend to deny their limits, leaders of brief groups
must act as group timekeeper, periodically reminding the group how much time
has passed and how much remains. The leader should regularly make comments
such as: “This is our twelfth meeting. We’re two-thirds done, but we still have six
more sessions. It might be wise to spend a few minutes today reviewing what
we’ve done, what goals remain, and how we should invest our remaining time.”
• Leaders must also attend to the transfer of learning, encouraging clients to apply
what they have learned in the group to their situations outside the group. They
must emphasize that treatment is intended to set change in motion, but not
necessarily to complete the process within the confines of the scheduled treatment.
The work of therapy will continue to unfold long after the sessions stop.
• Leaders should attempt to turn the disadvantages of time limitations into an
advantage. Since the time-limited therapy efforts of Carl Rogers, we have known
that imposed time limits may increase efficiency and energize the therapy.35 Also,
the fixed, imminent ending may be used to heighten awareness of existential
dimensions of life: time is not eternal; everything ends; there will be no magic
problem solver; the immediate encounter matters; the ultimate responsibility rests
within, not without.36
• Keep in mind that the official name of the group does not determine the work of
therapy. In other words, just because the group is made up of recently divorced
individuals or survivors of sex abuse does not mean that the focus of the group is
“divorce” or “sexual abuse.” It is far more effective for the group’s focus to be
interactional, directed toward those aspects of divorce or abuse that have
ramifications in the here-and-now of the group. For example, clients who have
been abused can work on their shame, their rage, their reluctance to ask for help,
their distrust of authority (that is, the leaders), and their difficulty in establishing

intimate relationships. Groups of recently divorced members will work most
profitably not by a prolonged historical focus on what went wrong in the marriage
but by examining each member’s problematic interpersonal issues as they manifest
in the here-and-now of the group. Members must be helped to understand and
change these patterns so that they do not impair future relationships.
• The effective group therapist should be flexible and use all means available to
increase efficacy. Techniques from cognitive or behavioral therapy may be
incorporated into the interactional group to alleviate symptomatic distress. For
example, the leader of a group for binge eating may recommend that members
explore the relationship between their mood and their eating in a written journal, or
log their food consumption, or meditate to reduce emotional distress. But this is by
no means essential. Brief group work that focuses on the interpersonal concerns
that reside beneath the food-related symptoms is as effective as brief group work
that targets the disordered eating directly.37 In other words, therapists can think of
symptoms as issuing from disturbances in interpersonal functioning and alleviate
the symptom by repairing the interpersonal disturbances.†
• Time is limited, but leaders must not make the mistake of trying to save time by
abbreviating the pregroup individual session. On the contrary, leaders must
exercise particularly great care in preparation and selection. The most important
single error made by busy clinics and HMOs is to screen new clients by phone and
immediately introduce them into a group without an individual screening or
preparatory session. Brief groups are less forgiving of errors than long-term
groups. When the life of the group is only, say, twelve sessions, and two or three of
those sessions are consumed by attending to an unsuitable member who then drops
out (or must be asked to leave), the cost is very high: the development of the group
is retarded, levels of trust and cohesion are slower to develop, and a significant
proportion of the group’s precious time and effectiveness is sacrificed.
• Use the pregroup individual meeting not only for standard group preparation but
also to help clients reframe their problems and sharpen their goals so as to make
them suitable for brief therapy.38 Some group therapists will use the first group
meeting to ask each client to present his/her interpersonal issues and treatment
goals.39
Some clinicians have sought ways to bridge the gap between brief and longer-term
treatment. One approach is to follow the brief group with booster group sessions
scheduled at greater intervals, perhaps monthly, for another six months.40 Another
approach offers clients a brief group but provides them with the option of signing on for
another series of meetings. One program primarily for clients with chronic illness consists
of a series of twelve-week segments with a two-week break between segments. 41
Members may enter a segment at any time until the sixth week, at which time the group
becomes a closed group. A client may attend one segment and then choose at some later
point to enroll for another segment. The program has the advantage of keeping all clients,
even the long-term members, goal-focused, as they reformulate their goals each segment.

Are brief groups effective? Outcome research on brief group therapy has increased
substantially over the past ten years. An analysis of forty-eight reports of brief therapy
groups (both cognitive-behavioral and dynamic /interpersonal) for the treatment of
depression demonstrated that groups that meet, on average, for twelve sessions produced
significant clinical improvement: group members were almost three times more likely to
improve than clients waiting for treatment.42 Furthermore, therapy groups add
substantially to the effect of pharmacotherapy in the treatment of depression.43 Brief
groups for clients with loss and grief have also been proven effective and are significantly
more effective than no treatment. 44 Both expressive-interpretive groups and supportive
groups have demonstrated significant effects with this clinical population.45
A study of brief interpersonal group therapy for clients with borderline personality
disorder reported improvement in clients’ mood and behavior at the end of twenty-five
sessions.46 Brief group therapy is also effective in the psychological treatment of the
medically ill:47 it improves coping and stress management, reduces mood and anxiety
symptoms, and improves self-care.
Some less salubrious findings have also been reported. In a comparison study of short-
term group, long-term group, brief individual, and long-term individual therapies, the
short-term group was the least effective of the four modalities.48 In a study in which
subjects were randomly assigned to short-term group treatment and short-term individual
treatment, the investigators found significant improvement in both groups and no
significant differences between them—except that subjectively the members preferred
brief individual to brief group treatment.49
In sum, research demonstrates the effectiveness of brief group therapy. However, there
is no evidence that brief therapy is superior to longer-term therapy.50 In other words, if
brief groups are necessary, we can lead them with confidence: we know there is much we
can offer clients in the brief format. But don’t be swept away by the powerful
contemporary press for efficiency. Don’t make the mistake of believing that a brief,
streamlined therapy approach offers clients more than longer-term therapy. One of the
architects of the NIMH Collaborative Treatment of Depression Study, one of the largest
psychotherapy trial conducted, has stated that the field has likely oversold the power of
brief psychotherapy.51
Size of the Group
My own experience and a consensus of the clinical literature suggest that the ideal size of
an interactional therapy group is seven or eight members, with an acceptable range of five
to ten members. The lower limit of the group is determined by the fact that a critical mass
is required for an aggregation of individuals to become an interacting group. When a
group is reduced to four or three members, it often ceases to operate as a group; member
interaction diminishes, and therapists often find themselves engaged in individual therapy
within the group. The groups lack cohesiveness, and although attendance may be good, it

is often due to a sense of obligation rather than a true alliance. Many of the advantages of
a group, especially the opportunity to interact and analyze one’s interaction with a large
variety of individuals, are compromised as the group’s size diminishes. Furthermore,
smaller groups become passive, suffer from stunted development, and frequently develop
a negative group image.52 Obviously the group therapist must replace members quickly,
but appropriately. If new members are unavailable, therapists do better to meld two small
groups rather than to continue limping along with insufficient membership in both.
The upper limit of therapy groups is determined by sheer economic principles. As the
group increases in size, less and less time is available for the working through of any
individual’s problems. Since it is likely that one or possibly two clients will drop out of the
group in the course of the initial meetings, it is advisable to start with a group slightly
larger than the preferred size; thus, to obtain a group of seven or eight members, many
therapists start a new group with eight or nine. Starting with a group size much larger than
ten in anticipation of dropouts may become a self-fulfilling prophecy. Some members will
quit because the group is simply too large for them to participate productively. Larger
groups of twelve to sixteen members may meet productively in day hospital settings,
because each member is likely to have many other therapeutic opportunities over the
course of each week and because not all members will necessarily participate in each
group session.
To some extent, the optimal group size is a function of the duration of the meeting: the
longer the meeting, the larger the number of participants who can profitably engage in the
group. Thus, many of the marathon therapy groups of past years had as many sixteen
members. Groups such as Alcoholics Anonymous and Recovery, Inc. that do not focus on
interaction may range from twenty to eighty. Psychoeducational groups for conditions
such as generalized anxiety may meet effectively with twenty to thirty participants. These
groups actively discourage individual disclosure and interaction, relying instead on the
didactic imparting of information about anxiety and stress reduction.53 Similar findings
have been reported in the treatment of panic disorder and agoraphobia.54
The large-group format has also been used with cancer patients, often with training in
stress reduction and self-management of illness symptoms and medical treatment side
effects. These groups may contain forty to eighty participants meeting weekly for two
hours over a course of six weeks.55 If you think of the health care system as a pyramid,
large groups of this type are part of the broad base of accessible, inexpensive treatment at
the system’s entry level. For many, this provision of knowledge and skills is sufficient.
Clients who require more assistance may move up the pyramid to more focused or
intensive interventions.56
A range of therapeutic factors may operate in these groups. Large homogeneous groups
normalize, destigmatize, activate feelings of universality, and offer skills and knowledge
that enhance self-efficacy. AA groups use inspiration, guidance, and suppression; the large
therapeutic community relies on group pressure and interdependence to encourage reality
testing, to combat regression, and to instill a sense of individual responsibility toward the
social community.

Group size is inversely proportional to interaction. One study investigated the
relationship between group size and the number of different verbal interactions initiated
between members in fifty-five inpatient therapy groups. The groups ranged in size from
five to twenty participants. A marked reduction in interactions between members was
evident when group size reached nine members, and another when it reached seventeen
members. The implication of the research is that, in inpatient settings, groups of five to
eight offer the greatest opportunity for total client participation.57
Several studies of non-therapy groups suggest that as the size of a group increases, there
is a corresponding tendency for members to feel disenfranchised and to form cliques and
disruptive subgroups.58 Furthermore, only the more forceful and aggressive members are
able to express their ideas or abilities.59 A comparison of twelve-member and five-
member problem-solving groups indicates that the larger groups experience more
dissatisfaction and less consensus.60
PREPARATION FOR GROUP THERAPY
There is great variation in clinical practice regarding individual sessions with clients prior
to group therapy. Some therapists, after seeing prospective clients once or twice in
selection interviews, do not meet with them individually again, whereas others continue
individual sessions until the client starts in the group. If several weeks are required to
accumulate sufficient members, the therapist is well advised to continue to meet with each
member periodically to prevent significant attrition. Even in settings with plenty of
appropriate group therapy referrals it is important to maintain client momentum and
interest. One way to do this is to set a firm start date for the group and then focus
energetically on recruitment and assessment. A group leader may need to invest twenty to
twenty-five hours to assemble one group.
Some therapists prefer to see the client several times in individual sessions in order to
build a relationship that will keep members in the group during early periods of
discouragement and disenchantment. It is my clinical impression that the more often
clients are seen before entering the group, the less likely they are to terminate prematurely
from the group. Often the first step in the development of bonds among members is their
mutual identification with a shared person: the therapist. Keep in mind that the purpose of
the individual pregroup sessions is to build a therapeutic alliance. To use the sessions
primarily for anamnestic purposes is not a good use of clinical time; it suggests to the
client that anamnesis is central to the therapy process.
One other overriding task must be accomplished in the pregroup interview or
interviews: the preparation of the client for group therapy. If I had to choose the one area
where research has the greatest relevance for practice, it would be in the preparation of
clients for group therapy. There is highly persuasive evidence that pregroup preparation
expedites the course of group therapy. Group leaders must achieve several specific goals

in the preparatory procedure:
• Clarify misconceptions, unrealistic fears, and expectations
• Anticipate and diminish the emergence of problems in the group’s development
• Provide clients with a cognitive structure that facilitates effective group
participation
• Generate realistic and positive expectations about the group therapy
Misconceptions About Group Therapy
Certain misconceptions and fears about group therapy are so common that if the client
does not mention them, the therapist should point them out as potential problems. Despite
powerful research evidence on the efficacy of group therapy, many people still believe that
group therapy is second-rate. Clients may think of group therapy as cheap therapy—an
alternative for people who cannot afford individual therapy or a way for managed health
care systems to increase profits. Others regard it as diluted therapy because each member
has only twelve to fifteen minutes of the therapist’s time each week. Still others believe
that the raison d’être of group therapy is to accommodate a number of clients that greatly
exceeds the number of staff therapists.
Let us examine some surveys of public beliefs about group therapy. A study of 206
college students consisting of students seeking counseling and a comparable number of
psychology students identified three common misconceptions:
1. Group therapy is unpredictable or involves a loss of personal control—for
example, groups may coerce members into self-disclosure.
2. Group therapy is not as effective as individual therapy because effectiveness is
proportional to the attention received from the therapist.
3. Being in a group with many individuals with significant emotional disturbance is
in itself detrimental.61
A British National Health Service study of sixty-nine moderately distressed clients
seeking therapy reported that more than 50 percent declared that they would not enter
group therapy even if no other treatment were available. Concerns cited included the fear
of ridicule and shame, the lack of confidentiality, and the fear of being made worse
through some form of contagion. What are some of the sources of this strong antigroup
bias? For many clients seeking therapy, difficulties with their peer and social group or
family is the problem. Hence, groups in general are distrusted, and the individual therapy
setting is considered the protected, safe, and familiar zone. This is particularly the case for
those with no prior experience in therapy.62
In general, the media and fictional portrayals of group therapy are vastly inaccurate and
often portray therapy groups in a mocking, ridiculing fashion.y Reality television shows
may also play a role. They speak to our unconscious fears of being exposed and extruded

from our group because we are found to be defective, deficient, stimulate envy or are
deemed to be the “weakest link.”63 Whatever their sources, such misconceptions and
apprehensions must be countered; otherwise these strong negative expectations may make
successful group therapy outcome unlikely.†
Nor are these unfavorable expectations limited to the general public or to clients. A
survey of psychiatric residents found similar negative attitudes toward the efficacy of
group therapy.64 Lack of exposure in one’s training is part of the problem, but the strength
of resistances to remedying these training shortfalls suggest that antigroup attitudes may
be deeply rooted and even unconscious. Thus, it should not surprise us to find such
attitudes within institutional and administrative leadership.
In addition to evaluative misconceptions, clients usually harbor procedural
misconceptions and unrealistic interpersonal fears. Many of these are evident in the
following dream, which a client reported at her second pregroup individual session shortly
before she was to attend her first group meeting:
• I dreamed that each member of the group was required to bring cookies to the
meeting. I went with my mother to buy the cookies that I was to take to the meeting.
We had great difficulty deciding which cookies would be appropriate. In the
meantime, I was aware that I was going to be very late to the meeting, and I was
becoming more and more anxious about getting there on time. We finally decided
on the cookies and proceeded to go to the group. I asked directions to the room
where the group was to meet, and was told that it was meeting in room 129A. I
wandered up and down a long hall in which the rooms were not numbered
consecutively and in which I couldn’t find a room with an “A.” I finally discovered
that 129A was located behind another room and went into the group. When I had
been looking for the room, I had encountered many people from my past, many
people whom I had gone to school with and many people whom I had known for a
number of years. The group was very large, and about forty or fifty people were
milling around the room. The members of the group included members of my
family—most specifically, two of my brothers. Each member of the group was
required to stand in front of a large audience and say what they thought was their
difficulty and why they were there and what their problems were. The whole dream
was very anxiety-provoking, and the business of being late and the business of
having a large number of people was very distracting.
Several themes are abundantly clear in this dream. The client anticipated the first group
meeting with considerable dread. Her concern about being late reflected a fear of being
excluded or rejected by the group. Furthermore, since she was starting in a group that had
already been meeting for several weeks, she feared that the others had progressed too far,
that she would be left behind and could never catch up. (She could not find a room with an
“A” marked on it.) She dreamed that the group would number forty or fifty. Concerns
about the size of the group are common; members fear that their unique individuality will
be lost as they become one of the mass. Moreover, clients erroneously apply the model of
the economic distribution of goods to the group therapeutic experience, assuming that the

size of the crowd is inversely proportional to the goods received by each individual.
The dream image of each member confessing problems to the group audience reflects
one of the most basic and pervasive fears of individuals entering a therapy group: the
horror of having to reveal oneself and to confess shameful transgressions and fantasies to
an alien audience. What’s more, members imagine a critical, scornful, ridiculing, or
humiliating response from the other members. The experience is fantasized as an
apocalyptic trial before a stern, uncompassionate tribunal. The dream also suggests that
pregroup anticipation resulted in a recrudescence of anxiety linked to early group
experiences, including those of school, family, and play groups. It is as if her entire social
network—all the significant people and groups she had encountered in her life—would be
present in this group. (In a metaphorical sense, this is true: to the degree that she had been
shaped by other groups and other individuals, to the degree that she internalized them, she
would carry them into the group with her since they are part of her character structure;
furthermore, she would, transferentially, re-create in the therapy group her early
significant relationships.)
It is clear from the reference to room 129 (an early schoolroom in her life) that the
client was associating her impending group experience with a time in her life when few
things were more crucial than the acceptance and approval of a peer group. Furthermore,
she anticipated that the therapist would be like her early teachers: an aloof, unloving
evaluator.
Closely related to the dread of forced confession is the concern about confidentiality.
The client anticipated that there would be no group boundaries, that every intimacy she
disclosed would be known by every significant person in her life. Other common concerns
of individuals entering group therapy, not evident in this dream, include a fear of mental
contagion, of being made sicker through association with ill comembers. Often, but not
exclusively, this is a preoccupation of clients with fragile ego boundaries who lack a solid,
stable sense of self.
The anxiety about regression in an unstructured group and being helpless to resist the
pull to merge and mesh with others can be overwhelming. In part, this concern is also a
reflection of the self-contempt of individuals who project onto others their feelings of
worthlessness. Such dynamics underlie the common query, “How can the blind lead the
blind?” Convinced that they themselves have nothing of value to offer, some clients find it
inconceivable that they might profit from others like themselves. Others fear their own
hostility. If they ever unleash their rage, they think, it will engulf them as well as others.
The notion of a group where anger is freely expressed is terrifying, as they think silently,
“If others only knew what I really thought about them.”
All of these unrealistic expectations that, unchecked, lead to a rejection or a blighting of
group therapy can be allayed by adequate preparation of the client. Before outlining a
preparation procedure, I will consider four problems commonly encountered early in the
course of the group that may be ameliorated by preparation before therapy begins.

Common Group Problems
1. One important source of perplexity and discouragement for clients early in therapy
is perceived goal incompatibility. They may be unable to discern the congruence
between group goals (such as group integrity, construction of an atmosphere of
trust, and an interactional focus) and their individual goals (relief of suffering).
What bearing, members may wonder, does a discussion of their personal reactions
to other members have on their symptoms of anxiety, depression, phobias,
impotence, or insomnia?
2. A high turnover in the early stages of a group is, as I have discussed, a major
impediment to the development of an effective group. The therapist, from the very
first contact with a client, should discourage irregular attendance and premature
termination. The issue is more pressing than in individual therapy, where absences
and tardiness can be profitably investigated and worked through. In the initial
stages of the group, irregular attendance results in a discouraged and disconnected
group.
3. Group therapy, unlike individual therapy, often does not offer immediate comfort.
Clients may be frustrated by not getting enough “airtime” in the first few meetings,
they may feel deprived of their specialness,† or they may feel anxious about the
task of direct interpersonal interaction. The therapist should anticipate and address
this frustration and anxiety in the preparatory procedure. This is a particular
challenge for clients who have found individual therapy to be narcissistically
gratifying.
4. Subgrouping and extragroup socializing, which has been referred to as the
Achilles’ heel of group therapy, may be encountered at any stage of the group. This
complex problem will be considered in detail in chapter 12. Here it is sufficient to
point out that the therapist may begin to shape the group norms regarding
subgrouping in the very first contact with the clients.
A System of Preparation
There are many approaches to preparing clients for group therapy. The simplest and most
practical in the harried world of everyday clinical practice is to offer the client the
necessary information in the pregroup interview (s). I am careful to set aside sufficient
time for this presentation. I attempt to see clients at least twice before introducing them
into the group. But even if I see someone only once, I reserve at least half the time to
address each of the foregoing misconceptions and initial problems of group therapy.
Misconceptions should be explored in detail and each one corrected by an accurate and
complete discussion. I share with the client my predictions about the early problems in
therapy and present a conceptual framework and clear guidelines for effective group
behavior. Each client’s preparation must be individualized according to the presenting

complaints, questions and concerns raised in the interview, and level of sophistication
regarding the therapy process. Two situations require particular attention from the
therapist: the therapy neophyte and the client who presents with cross-cultural issues. The
client who has never been in any form of therapy may find group therapy particularly
challenging and may require additional pregroup individual preparation.† Clients from
other cultures may be particularly threatened by the intimate personal exposure in the
group. The pregroup preparation sessions provide the therapist the opportunity to explore
the impact of the client’s culture on his or her attitudes, beliefs, and identity and to
demonstrate the therapist’s genuine willingness to enter the client’s world.65
I have found a preparatory interview with the following objectives to be of considerable
value:
1. Enlist clients as informed allies. Give them a conceptual framework of the
interpersonal basis of pathology and how therapy works.
2. Describe how the therapy group addresses and corrects interpersonal problems.
3. Offer guidelines about how best to participate in the group, how to maximize the
usefulness of group therapy.
4. Anticipate the frustrations and disappointments of group therapy, especially of the
early meetings.
5. Offer guidelines about duration of therapy. Make a contract about attendance in
group.
6. Instill faith in group therapy; raise expectations about efficacy.
7. Set ground rules about confidentiality and subgrouping.
Now, to flesh out each of these points in turn.
1. First, I present clients with a brief explanation of the interpersonal theory of
psychiatry, beginning with the statement that although each person manifests his or her
problems differently, all who seek help from psychotherapy have in common the basic
difficulty of establishing and maintaining close and gratifying relationships with others. I
remind them of the many times in their lives that they have undoubtedly wished to clarify
a relationship, to be really honest about their positive and negative feelings with someone
and get reciprocally honest feedback. The general structure of society, however, does not
often permit such open communication. Feelings are hurt, relationships are ruptured,
misunderstandings arise, and, eventually, communication ceases.
2. I describe the therapy group, in simple, clear language, as a social laboratory in
which such honest interpersonal exploration is not only permitted but encouraged. If
people are conflicted in their methods of relating to others, then a social situation
encouraging honest interaction provides a precious opportunity to learn many valuable
things about themselves. I emphasize that working on their relationships directly with
other group members will not be easy; in fact, it may even be stressful. But it is crucial
because if they can completely understand and work out their relationships with the other

group members, there will be an enormous carryover into their outside world: they will
discover pathways to more rewarding relationships with significant people in their life
now and with people they have yet to meet.
3. I advise members that the way to use therapy best is to be honest and direct with their
feelings in the group at that moment, especially their feelings toward the other group
members and the therapists. I emphasize this point many times and refer to it as the core
of group therapy. I say that clients may, as they develop trust in the group, reveal intimate
aspects of themselves, but that the group is not a forced confessional and that people have
different rates of developing trust and revealing themselves. The group is a forum for risk
taking, I emphasize, and I urge members to try new types of behavior in the group setting.
4. I predict certain stumbling blocks and warn clients that they may feel puzzled and
discouraged in the early meetings. It will, at times, not be apparent how working on group
problems and intermember relationships can be of value in solving the problems that
brought them to therapy. This puzzlement, I stress, is to be expected in the typical therapy
process. I tell them that many people at first find it painfully difficult to reveal themselves
or to express directly positive or negative feelings, and I discuss the tendency to withdraw
emotionally, to hide feelings, to let others express one’s feelings, to form concealing
alliances with others. I also predict that they are likely to develop feelings of frustration or
annoyance with the therapist and that they will expect answers that the therapist cannot
supply. Help will often be forthcoming from other group members, however difficult it
may be for them to accept this fact.
5. For clients entering an open-ended psychotherapy group I emphasize that the
therapeutic goals of group therapy are ambitious because we desire to change behavior
and attitudes many years in the making. Treatment is therefore gradual and may be long,
often with no important change occurring for months. I strongly urge clients to stay with
the group and to ignore any inclination to leave the group before giving it a real chance. It
is almost impossible to predict the eventual effectiveness of the group during the first
dozen meetings. Thus, I urge them to suspend judgment and to make a good-faith
commitment of at least twelve meetings before even attempting to evaluate the ultimate
usefulness of the group. For clients who are entering a briefer group therapy, I say that the
group offers an outstanding opportunity to do a piece of important work that they can
build upon in the future. Each session is precious, and it is in their interest and the interest
of the other group members to attend each one of the limited number scheduled.
6. It is vitally important for the therapist to raise expectations, to instill faith in group
therapy, and to dispel the false notion that group therapy is second-class therapy. Research
tells us that clients who enter therapy expecting it to be successful will exert much greater
effort in the therapy, will develop a stronger therapeutic alliance, and are significantly
more likely to succeed.66 This effect of client pretherapy expectancies is even greater for
less structured therapies that may generate more client anxiety and uncertainty.67 In my
preparation, therefore, I provide a brief description of the history and development of
group therapy—how group therapy passed from a stage during World War II when it was
valued for its economic advantages (that is, it allowed psychotherapists to reach a large

number of people in need), to its current position in the field, where it clearly has
something unique to offer and is often the treatment of choice. I inform clients that
psychotherapy outcome studies demonstrate that group therapy is as efficacious as any
mode of individual therapy.
7. There are a few ground rules. Nothing is more important than honestly sharing
perceptions and feelings about oneself and other members in the group. Confidentiality, I
state, is as essential in group therapy as it is in any therapist-client relationship. For
members to speak freely, they must have confidence that their statements will remain
within the group. In my group therapy experience, I can scarcely recall a single significant
breach of confidence and can therefore reassure group members on this matter.z68
It is important not to corrode client trust regarding confidentiality. However, at the same
time, in the spirit of obtaining informed consent for treatment, I also inform the client of
my mandatory professional duties to report certain offenses.69 In virtually all jurisdictions
the therapist must report situations in which the actions of the client are, or will
imminently be, harmful to self or others. Occasionally, members may inquire whether they
can relate aspects of the group therapy discussion with a spouse or a confidant. I urge
them to discuss only their own experience: the other members’ experiences and certainly
their names should be kept in strictest confidence.
In addition to the ground rules of honesty and confidentiality, I make a point of
discussing the issue of contacts outside the group between members which, in one form or
another, will occur in every psychotherapy group. Two particularly important points must
be stressed:
1. The group provides an opportunity for learning about one’s problems in social
relationships; it is not an assembly for meeting and making social friends. On the contrary,
if the group is used as a source of friends it loses its therapeutic effectiveness. In other
words, the therapy group teaches one how to develop intimate, long-term relationships, but
it does not provide these relationships. It is a bridge, not the destination. It is not life but a
dress rehearsal for life.
2. If by chance or design, however, members do meet outside the group, it is their
responsibility to discuss the salient aspects of that meeting inside the group. It is
particularly useless for therapists to prohibit extragroup socializing or, for that matter, to
declare any injunctions about client behavior. Almost invariably during the therapy, group
members will engage in some outside socializing and in the face of the therapist’s
prohibition may be reluctant to disclose it in the group. As I shall elaborate in the next
chapter, extragroup relationships are not harmful per se (in fact, they may be extremely
important in the therapeutic process); what impedes therapy is the conspiracy of silence
that often surrounds such meetings.
An approach of injunction and prohibition merely draws group members into the issue
of rule setting and rule breaking. It is far more effective to explain at length why certain
actions may interfere with therapy. With subgrouping, for example, I explain that
friendships among group members often prevent them from speaking openly to one

another in the group. Members may develop a sense of loyalty to a dyadic relationship and
may thus hesitate to betray the other by reporting their conversations back to the group.
Yet such secrecy will conflict with the openness and candor so essential to the therapy
process. The primary task of therapy group members is, I remind them, to learn as much
as possible about the way each individual relates to each other person in the group. All
events that block that process ultimately obstruct therapy. Occasionally group members
may wish to make a secret disclosure to the group leader. Almost always it is best that the
disclosure be shared with the group. Group leaders must never, in advance, agree to
secrecy but instead promise to use discretion and their best clinical judgment.
This strategy of providing full information to the members about the effects of
extragroup socializing provides the therapist with far greater leverage than the strategy of
the ex cathedra “thou shall not.” If group members engage in secretive subgrouping, you
do not have to resort to the ineffectual, misdirected “Why did you break my rules?” but
instead can plunge into the heart of resistance by inquiring, “How come you’re sabotaging
your own therapy?”

In summary, this cognitive approach to group therapy preparation has several goals: to
provide a rational explanation of the therapy process; to describe what types of behavior
are expected of group members; to establish a contract about attendance; to raise
expectations about the effects of the group; to predict (and thus to ameliorate) problems
and discomfort in early meetings. Underlying these words is the process of demystification
. Therapists convey the message that they respect the client’s judgment and intelligence,
that therapy is a collaborative venture, that leaders are experts who operate on a rational
basis and are willing to share their knowledge with the client. One final point is that
comprehensive preparation also enables the client to make an informed decision about
whether to enter a therapy group.
Though this discussion is geared toward a longer-term interactional group, its basic
features may be adapted to any other type of group therapy. In brief therapy groups
relying on different therapeutic factors—for example, cognitive-behavioral groups—the
relevant details of the presentation would have to be altered, but every therapy group
profits from preparation of its members.† If clinical exigencies preclude a thorough
preparation, then a short preparation is better than none at all. In chapter 15, I describe a
three-minute preparation I provide at the start of an acute inpatient group.
Other Approaches to Preparation
Straightforward cognitive preparation presented a single time to a client may not be
sufficiently powerful. Clients are anxious during their pregroup interviews and often recall
astonishingly little of the content of the therapist’s message or grossly misunderstand key
points. For example, some group participants whom I asked to remain in the group for
twelve sessions before evaluating its usefulness understood me to say that the group’s

entire life span would be twelve sessions.
Consequently, it is necessary to repeat and to emphasize deliberately many key points
of the preparation both during the pregroup sessions and during the first few sessions of
the group. For my ambulatory groups that meet once a week, I prepare a weekly written
summary that I mail out to all the group members after each session (see chapter 14).
These summaries provide an excellent forum to repeat in writing essential parts of the
preparation procedure. When a new member joins an ongoing group, I provide additional
preparation by requesting that he or she read the group summaries of the previous six
meetings.
Many therapists have described other methods to increase the potency of the
preparatory procedure. Some have used another group member to sponsor and to prepare a
new member.70 Others have used a written document for the new client to study before
entering a group. The appendix to this book contains an example of a written handout to
be used as a supplement for preparing clients entering a group. It stresses focusing on the
here-and-now, assuming personal responsibility, avoiding blaming others, avoiding giving
suggestions and fostering dependency, learning to listen to others, becoming aware both of
feelings and of thoughts, and attempting to experiment with intimacy and with new
behavior. We emphasize feedback and offer prospective members specific instructions
about how to give and receive feedback: for example, be specific, give it as soon as
possible, be direct, share the positive and the negative, tell how the other makes you feel,
don’t deal with why but with what you see and feel, acknowledge the feedback, don’t
make excuses, seek clarification, think about it, and beware of becoming defensive.71
Other preparation techniques include observation of an audiotape or videotape of
meetings.† For reasons of confidentiality, this must be a professionally marketed tape in
the public domain or a tape of a simulated group meeting with staff members or
professional actors playing the roles of members. The scripts may be deliberately designed
to demonstrate the major points to be stressed in the preparatory phase.
An even more powerful mode of preparing clients is to provide them with personal
training in desired group behavior.†72 Several experiential formats have been described.
One brief group therapy team, for example, employs a two-part preparation. First, each
group member has an individual meeting to establish a focus and goals for therapy.
Afterward, prospective group members participate in an experiential single-session
workshop at which eighteen to twenty clients perform a series of carefully selected
structured interactional exercises, some involving dyads, some triads, and some the entire
group.73
Another study used four preparatory sessions, each of which focused on a single
concept of pregroup training: (1) using the here-and-now, (2) learning how to express
feelings, (3) learning to become more self-disclosing, and (4) becoming aware of the
impact one has and wishes to have on others. The researchers handed out cognitive
material in advance and designed structured group exercises to provide experiential
learning about each concept.74 Other projects use role playing to simulate group therapy

interaction.75
In general, the more emotionally alive and relevant the preparation is, the greater its
impact will be. Some research suggests that it is the active, experiential rather than the
cognitive or passive, observing component of the pretraining that may have the greatest
impact.76
Much current preparation research centers on the client’s motivation and change
readiness.aa77 The focus on motivation as a target for intervention (rather than a
prerequisite for treatment) originated in the treatment of addiction and has subsequently
been applied effectively for clients with eating disorders and perpetrators of sexual abuse
—clinical populations well recognized for denial and resistance to change.78
In the future, we can expect interactive computer technology to generate even more
effective preparatory programs. However, the existing approaches, used singly or in
combination, can be highly effective. Much research evidence, to which I now turn, attests
to the general effectiveness of these techniques.
Research Evidence
In a controlled experiment, my colleagues and I tested the effectiveness of a brief
cognitive preparatory session.79 Of a sample of sixty clients awaiting group therapy, half
were seen in a thirty-minute preparatory session, and the other half were seen for an equal
period in a conventional interview dedicated primarily to history-taking. Six therapy
groups (three of prepared clients, three of unprepared clients) were organized and led by
group therapists unaware that there had been an experimental manipulation. (The
therapists believed only that all clients had been seen in a standard intake session.) A study
of the first twelve meetings demonstrated that the prepared groups had more faith in
therapy (which, in turn, positively influences outcome) and engaged in significantly more
group and interpersonal interaction than did the unprepared groups, and that this
difference was as marked in the twelfth meeting as in the second.80 The research design
required that identical preparation be given to each participant. Had the preparation been
more thorough and more individualized for each client, its effectiveness might have been
greater.
The basic design and results of this project—a pregroup preparation sample, which is
then studied during its first several group therapy meetings and shown to have a superior
course of therapy compared with a sample that was not properly prepared—has been
replicated many times. The clinical populations have varied, and particular modes of
preparation and process and outcome variables have grown more sophisticated. But the
amount of corroborative evidence supporting the efficacy on both group processes and
client outcomes of pregroup preparation is impressive. 81 Furthermore, few studies fail to
find positive effects of preparation on clients’ work in group therapy.82
Pregroup preparation improves attendance83 and increases self-disclosure, self-

exploration, and group cohesion,84 although the evidence for lower dropout rates is less
consistent.85 Prepared group members express more emotion;86 assume more personal
responsibility in a group;87 disclose more of themselves;88 show increased verbal, work-
oriented participation; 89 are better liked by the other members;90 report less anxiety;91 are
more motivated to change;92 show a significant decrease in depression;93 improve in
marital adjustment and ability to communicate;94 are more likely to attain their primary
goals in therapy;95 and have fewer erroneous conceptions about the group procedure.96
Research shows that cognitive preparation of clients in lower socioeconomic classes
results in greater involvement, group activity, and self-exploration.97 Even notoriously
hard to engage populations, such as domestic abusers, respond very positively to measures
aimed at enhancing attendance and participation.98
In summary, a strong research consensus endorses the value of pregroup client
preparation. Most of the findings demonstrate the beneficial impact of preparation on
intervening variables; a direct effect on global client outcome is more difficult to
demonstrate because the contributions of other important therapy variables obscure the
effect of preparation.99
The Rationale Behind Preparation
Let us consider briefly the rationale behind preparation for group therapy. The first
meetings of a therapy group are both precarious and vitally important: many members
grow unnecessarily discouraged and terminate therapy, and the group is in a highly fluid
state and maximally responsive to the influence of the therapist—who has the opportunity
to help the group elaborate therapeutic norms. The early meetings are a time of
considerable client anxiety, both intrinsic, unavoidable anxiety and extrinsic, unnecessary
anxiety.
The intrinsic anxiety issues from the very nature of the group. Individuals who have
encountered lifelong disabling difficulties in interpersonal relationships will invariably be
stressed by a therapy group that demands not only that they attempt to relate deeply to
other members but also that they discuss these relationships with great candor. In fact, as I
noted in chapter 9, clinical consensus and empirical research both indicate that anxiety
seems to be an essential condition for the initiation of change.100 In group therapy, anxiety
arises not only from interpersonal conflict but from dissonance, which springs from one’s
desire to remain in the group while at the same time feeling highly threatened by the group
task. An imposing body of evidence, however, demonstrates that there are limits to the
adaptive value of anxiety in therapy.101 An optimal degree of anxiety enhances motivation
and increases vigilance, but excessive anxiety will obstruct one’s ability to cope with
stress. White notes, in his masterful review of the evidence supporting the concept of an
exploratory drive, that excessive anxiety and fear are the enemies of environmental
exploration; they retard learning and decrease exploratory behavior in proportion to the
intensity of the fear.102 In group therapy, crippling amounts of anxiety may prevent the

introspection, interpersonal exploration, and testing of new behavior essential to the
process of change.
Much of the anxiety experienced by clients early in the group is not intrinsic to the
group task but is extrinsic, unnecessary, and sometimes iatrogenic. This anxiety is a
natural consequence of being in a group situation in which one’s expected behavior, the
group goals, and their relevance to one’s personal goals are exceedingly unclear. Research
with laboratory groups demonstrates that if the group’s goals, the methods of goal
attainment, and expected role behavior are ambiguous, the group will be less cohesive and
less productive and its members more defensive, anxious, frustrated, and likely to
terminate membership.103
Effective preparation for the group will reduce the extrinsic anxiety that stems from
uncertainty. By clarifying the group goals, by explaining how group and personal goals are
confluent, by presenting unambiguous guidelines for effective behavior, by providing the
client with an accurate formulation of the group process, the therapist reduces uncertainty
and the accompanying extrinsic anxiety.
A systematic preparation for group therapy by no means implies a rigid structuring of
the group experience. I do not propose a didactic, directive approach to group therapy but,
on the contrary, suggest a technique that will enhance the formation of a freely interacting,
autonomous group. By averting lengthy ritualistic behavior in the initial sessions and by
diminishing initial anxiety stemming from ambiguity, the group is enabled to plunge
quickly into group work.
Although some group therapists eschew systematic preparation for the group, all group
therapists attempt to clarify the therapeutic process and the behavior expected of clients:
Differences between therapists or between therapeutic schools are largely in the timing
and style of preparation. By subtle or even subliminal verbal and nonverbal reinforcement,
even the most nondirective therapist attempts to persuade a group to accept his or her
values about what is or is not important in the group process.104
Bureaucratic considerations add another component to preparation: informed consent.
Contemporary therapists are under increasing pressure to provide (and to document in the
record that it has been provided) sufficient information about treatment benefits, side
effects, costs, and alternatives to make an informed choice about their therapy.105
Furthermore, informed consent cannot be dispensed with in a single discussion but must
be revisited on a timely basis. Obtaining informed consent is rapidly evolving into a
standard of practice enshrined in the Ethics Guidelines of the American Psychological
Association106 and the American Psychiatric Association.107 Though this procedure may
seem onerous, it is here to stay, and adaptive therapists must find a way to transform it into
something useful: periodic frank discussions about the course of therapy convey respect
for the client and strengthen the therapeutic alliance.
One final practical observation about preparation is in order. Group therapists often find
themselves pressed to find group members. A sudden loss of members may provoke
therapists into hasty activity to rebuild the group, often resulting in the selection of

unsuitable, inadequately prepared members. The therapist then has to assume the position
of selling the group to the prospective member—a position that is generally obvious to the
client. The therapist does better to continue the group with reduced membership, to select
new members carefully, and then to present the group in such a way as to maximize a
client’s desire to join it. In fact, research indicates that the more difficult it is to enter a
group and the more one wants to join, the more the individual will subsequently value the
group.108 This is the general principle underlying initiation rites to fraternities and arduous
selection and admission criteria for many organizations. An applicant cannot but reason
that a group so difficult to join must be very valuable indeed.

Chapter 11
IN THE BEGINNING
The work of the group therapist begins long before the first group meeting. As I have
already emphasized, successful group outcome depends largely on the therapist’s effective
performance of the pretherapy tasks. In previous chapters, I discussed the crucial
importance of proper group selection, composition, setting, and preparation. In this
chapter I consider the birth and development of the group: first, the stages of development
of the therapy group, and then problems of attendance, punctuality, membership turnover,
and addition of new members—important issues in the life of the developing group.
FORMATIVE STAGES OF THE GROUP
Every therapy group, with its unique cast of characters and complex interaction, undergoes
a singular development. All the members begin to manifest themselves interpersonally,
each creating his or her own social microcosm. In time, if therapists do their job
effectively, members will begin to understand their interpersonal style and eventually to
experiment with new behavior. Given the richness of human interaction, compounded by
the grouping of several individuals with maladaptive styles, it is obvious that the course of
a group over many months or years will be complex and, to a great degree, unpredictable.
Nevertheless, group dynamic forces operate in all groups to influence their development,
and it is possible to describe an imperfect but nonetheless useful schema of developmental
phases.
One well-known group developmental theory postulates five stages: forming, storming,
norming, performing, and adjourning.1 This simple, rhythmic phrase captures well the
range of group development models articulated by diverse researchers and applies to both
time-limited and open-ended groups.†2
In general, groups are first preoccupied with the tasks of initial member engagement
and affiliation. This phase is followed by one with a focus on control, power, status,
competition, and individual differentiation. Next comes a long, productive working phase
marked by intimacy, engagement, and genuine cohesion. The final stage is termination of
the group experience. These models also share a premise that development is epigenetic—
that is, each stage builds on the success of preceding ones. Hence, early developmental
failures will express themselves throughout the group’s life. Another premise of
development is that groups are likely to regress under conditions threatening group
integrity.†
As group development unfolds, we see shifts in group member behavior and
communication. As the group matures, increased empathic, positive communication will
be evident. Members describe their experience in more personal, affective and less

intellectual ways. Group members focus more on the here-and-now, are less avoidant of
productive conflict, offer constructive feedback, are more disclosing, and are more
collaborative. Advice is replaced with exploration, and the group is more interactional,
self-directed and less leader centered.3 This developmental shift to more meaningful work
has also been demonstrated repeatedly in reliable studies of task and work groups and
correlates significantly with enhanced productivity and achievement.4
There are compelling reasons for you as the therapist to familiarize yourself with the
developmental sequence of groups. If you are to perform your task of assisting the group
to form therapeutic norms and to prevent the establishment of norms that hinder therapy,
then you must have a clear conception of the optimal development of a therapy group. If
you are to diagnose group blockage and to intervene strategically to encourage healthy
development, you must have a sense of favorable and of flawed development.
Furthermore, knowledge of a broad developmental sequence will provide you with a sense
of mastery and direction in the group; a confused and anxious leader engenders similar
feelings in the group members.
The First Meeting
The first group therapy session is invariably a success. Clients (as well as neophyte
therapists) generally anticipate it with such dread that they are always relieved by the
actual event. Any actions therapists take to reduce clients’ anxiety and unease are
generally useful. It is often helpful to call members a few days before the first meeting to
reestablish contact and remind them of the group’s beginning. Greeting group members
outside the group room before the first meeting or posting signs on the hallway directing
clients to the group room for the first meeting are easy and reassuring steps to take.
Some therapists begin the meeting with a brief introductory statement about the purpose
and method of the group (especially if they have not thoroughly prepared the clients
beforehand); others may simply mention one or two basic ground rules—for example,
honesty and confidentiality. The therapist may suggest that the members introduce
themselves; if the therapist instead remains silent, invariably some member will suggest
that the members introduce themselves. In North American groups the use of first names
is usually established within minutes. Then a very loud silence ensues, which, like most
psychotherapy silences, seems eternal but lasts only a few seconds.
Generally, the silence is broken by the individual destined to dominate the early stages
of the group, who will say, “I guess I’ll get the ball rolling,” or words to that effect.
Usually that person then recounts his or her reasons for seeking therapy, which often
elicits similar descriptions from other members. An alternative course of events occurs
when a member (perhaps spurred by the tension of the group during the initial silence)
comments on his or her social discomfort or fear of groups. This remark may stimulate
related comments from others who have similar feelings.
As I stressed in chapter 5, the therapist wittingly or unwittingly begins to shape the

norms of the group at its inception. This task can be more efficiently performed while the
group is still young. The first meeting is therefore no time for the therapist to be passive
and inactive;5 in chapter 5 I described a number of techniques to shape norms in a
beginning group.
The Initial Stage: Orientation, Hesitant Participation, Search for Meaning, Dependency
Two tasks confront members of any newly formed group. First, they must understand how
to achieve their primary task—the purpose for which they joined the group. Second, they
must attend to their social relationships in the group so as to create a niche for themselves
that will provide not only the comfort necessary to achieve their primary task but also
gratification from the sheer pleasure of group membership. In many groups, such as
athletic teams, college classrooms, and work settings, the primary task and the social task
are well differentiated.6 In therapy groups, although this fact is not often appreciated at
first by members, the tasks are confluent—a fact vastly complicating the group experience
of socially ineffective individuals.
Several simultaneous concerns are present in the initial meetings. Members, especially
if not well prepared by the therapist, search for the rationale of therapy; they may be
confused about the relevance of the group’s activities to their personal goals in therapy.
The initial meetings are often peppered with questions reflecting this confusion. Even
months later, members may wonder aloud, “How is this going to help? What does all this
have to do with solving my problems?”
At the same time, the members are attending to their social relationships: they size up
one another and the group. They search for viable roles for themselves and wonder
whether they will be liked and respected or ignored and rejected. Although clients
ostensibly come to a therapy group for treatment, social forces impel them to invest most
of their energy in a search for approval, acceptance, respect, or domination. To some,
acceptance and approval appear so unlikely that they defensively reject or depreciate the
group by mentally derogating the other members and by reminding themselves that the
group is unreal and artificial, or that they are too special to care about a group that requires
sacrificing even one particle of their prized individuality. Many members are particularly
vulnerable at this time.†7
In the beginning, the therapist is well advised to keep one eye on the group as a whole,
and the other eye on each individual’s subjective experience in this new group. Members
wonder what membership entails. What are the admission requirements? How much must
one reveal or give of oneself? What type of commitment must one make? At a conscious
or near-conscious level, they seek the answers to questions such as these and maintain a
vigilant search for the types of behavior that the group expects and approves. Most clients
crave both a deep, intimate one-to-one connection and a connection to the whole group.†8
Occasionally, however, a member with a very tenuous sense of self may fear losing his
identity through submersion in the group. If this fear is particularly pronounced it may

impede engagement in the group. For such individuals, differentiation trumps belonging.9
If the early group is puzzled, testing, and hesitant, then it is also dependent. Overtly and
covertly, members look to the leader for structure and answers as well as for approval and
acceptance. Many comments and reward-seeking glances are cast at you as members seek
to gain approval from authority. Your early comments are carefully scrutinized for
directives about desirable and undesirable behavior. Clients appear to behave as if
salvation emanates solely or primarily from you, if only they can discover what it is you
want them to do. There is considerable realistic evidence for this belief: you have a
professional identity as a healer, you host the group by providing a room, you prepare
members, and you charge a fee for your services. All of this reinforces their expectation
that you will take care of them. Some therapists unwittingly compound this belief by
absorbing the client projections of special powers and unconsciously offering unfulfillable
promise of succor.10
The existence of initial dependency thus stems from many sources: the therapeutic
setting, the therapist’s behavior, a morbid dependency state on the part of the client and, as
I discussed in chapter 7, the many irrational sources of the members’ powerful feelings
toward the therapist. Among the strongest of these is the human need for an omnipotent,
omniscient, all-caring parent or rescuer—a need that colludes with the infinite human
capacity for self-deception to create a yearning for and a belief in a superbeing.†
In young groups, the members’ fantasies play in concert to result in what Freud referred
to as the group’s “need to be governed by unrestricted force, its extreme passion for
authority, its thirst for obedience.”11 (Yet, who is God’s god? I have often thought that the
higher suicide rate among psychiatrists relative to other specialists is one tragic
commentary on this dilemma.12 Psychotherapists who are deeply depressed and who know
that they must be their own superbeing, their own ultimate rescuer, are more likely than
many of their clients to plunge into final despair.)
The content and communicational style of the initial phase tends to be relatively
stereotyped and restricted, resembling the interaction occurring at a cocktail party or
similar transient social encounters. Problems are approached rationally; the client
suppresses irrational aspects of his concerns in the service of support, etiquette, and group
tranquillity. Thus, at first, groups may endlessly discuss topics of apparently little
substantive interest to any of the participants; these cocktail party issues, however, serve
as a vehicle for the first interpersonal exploratory forays. Hence, the content of the
discussion is less important than the unspoken process: members size up one another, they
attend to such things as who responds favorably to them, who sees things the way they do,
whom to fear, whom to respect.
In the beginning, therapy groups often spend time on symptom description, previous
therapy experience, medications, and the like. The members often search for similarities.
Members are fascinated by the notion that they are not unique in their misery, and most
groups invest considerable energy in demonstrating how the members are similar. This
process often offers considerable relief to members (see the discussion of universality in
chapter 1) and provides part of the foundation for group cohesiveness. These first steps set

the stage for the later deeper engagement that is a prerequisite for effective therapy.13
Giving and seeking advice is another characteristic of the early group: clients seek
advice for problems with spouses, children, employers, and so on, and the group attempts
to provide some practical solution. As discussed in chapter 1, this guidance is rarely of
functional value but serves as a vehicle through which members can express mutual
interest and caring. It is also a familiar mode of communication that can be employed
before members understand how to work fully in the here-and-now.
In the beginning the group needs direction and structure. A silent leader will amplify
anxiety and foster regression.† This phenomenon occurs even in groups of
psychologically sophisticated members. For example, a training group of psychiatry
residents led by a silent, nondirective leader grew anxious at their first meeting and
expressed fears of what could happen in the group and who might become a casualty of
the experience. One member spoke of a recent news report of a group of seemingly
“normal” high school students who beat a homeless man to death. Their anxiety lessened
when the leader commented that they were all concerned about the harmful forces that
could be unleashed as a result of joining this group of seemingly “normal” residents.
The Second Stage: Conflict, Dominance, Rebellion
If the first core concern of a group is with “in or out,” then the next is with “top or
bottom.”14 In this second, “storming” stage, the group shifts from preoccupation with
acceptance, approval, commitment to the group, definitions of accepted behavior, and the
search for orientation, structure, and meaning, to a preoccupation with dominance, control,
and power. The conflict characteristic of this phase is among members or between
members and leader. Each member attempts to establish his or her preferred amount of
initiative and power. Gradually, a control hierarchy, a social pecking order, emerges.
Negative comments and intermember criticism are more frequent; members often
appear to feel entitled to a one-way analysis and judgment of others. As in the first stage,
advice is given but in the context of a different social code: social conventions are
abandoned, and members feel free to make personal criticism about a complainer’s
behavior or attitudes. Judgments are made of past and present life experiences and styles.
It is a time of “oughts” and “shoulds” in the group, a time when the “peercourt” 15 is in
session. Members make suggestions or give advice, not as a manifestation of deep
acceptance and understanding—sentiments yet to emerge in the group—but in the service
of jockeying for position.
The struggle for control is part of the infrastructure of every group. It is always present,
sometimes quiescent, sometimes smoldering, sometimes in full conflagration. If there are
members with strong needs to dominate, control may be the major theme of the early
meetings. A dormant struggle for control often becomes more overt when new members
are added to the group, especially new members who do not “know their place” and,
instead of making obeisance to the older members in accordance with their seniority, make

strong early bids for dominance.
The emergence of hostility toward the therapist is inevitable in the development of a
group. Many observers have emphasized an early stage of ambivalence to the therapist
coupled with resistance to self-examination and self-disclosure. Hostility toward the leader
has its source in the unrealistic, indeed magical, attributes with which clients secretly
imbue the therapist. Their expectations are so limitless that they are bound to be
disappointed by any therapist, however competent. Gradually, as they recognize the
therapist’s limitations, reality sets in and hostility to the leader dissipates.
This is by no means a clearly conscious process. The members may intellectually
advocate a democratic group that draws on its own resources but nevertheless may, on a
deeper level, crave dependency and attempt first to create and then destroy an authority
figure. Group therapists refuse to fill the traditional authority role: they do not lead in the
ordinary manner; they do not provide answers and solutions; they urge the group to
explore and to employ its own resources. The members’ wish lingers, however, and it is
usually only after several sessions that the group members come to realize that the
therapist will frustrate their yearning for the ideal leader.
Yet another source of resentment toward the leader lies in the gradual recognition by
each member that he or she will not become the leader’s favorite child. During the
pretherapy session, each member comes to harbor the fantasy that the therapist is his or
her very own therapist, intensely interested in the minute details of that client’s past,
present, and fantasy world. In the early meetings of the group, however, each member
begins to realize that the therapist is no more interested in him or her than in the others;
seeds are sown for the emergence of rivalrous, hostile feelings toward the other members.
Each member feels, in some unclear manner, betrayed by the therapist. Echoes of prior
issues with siblings may emerge and members begin to appreciate the importance of peer
interactions in the work of the group.†
These unrealistic expectations of the leader and consequent disenchantment are by no
means a function of childlike mentality or psychological naivete. The same phenomena
occur, for example, in groups of professional psychotherapists. In fact, there is no better
way for the trainee to appreciate the group’s proclivity both to elevate and to attack the
leader than to be a member of a training or therapy group and to experience these
powerful feelings firsthand. Some theorists16 take Freud’s Totem and Taboo†17 literally
and regard the group’s pattern of relationship with the leader as a recapitulation of the
primal horde patricide. Freud does indeed suggest at one point that modern group
phenomena have their prehistoric analogues in the mist of ancient, primal horde events:
“Thus the group appears to us as a revival of the primal horde. Just as primitive man
survives potentially in every individual, so the primal horde may arise once more out of
any random collection; insofar as men are habitually under the sway of group formation,
we recognize in it the survival of the primal horde.”18 The primal horde is able to free
itself from restrictive, growth-inhibiting bonds and progress to a more satisfying existence
only after the awesome leader has been removed.
The members are never unanimous in their attack on the therapist. Invariably, some

champions of the therapist will emerge from the group. The lineup of attackers and
defenders may serve as a valuable guide for the understanding of characterological trends
useful for future work in the group. Generally, the leaders of this phase, those members
who are earliest and most vociferous in their attack, are heavily conflicted in the area of
dependency and have dealt with intolerable dependency yearnings by reaction formation.
These individuals, sometimes labeled counterdependents, 19 are inclined to reject prima
facie all statements by the therapist and to entertain the fantasy of unseating and replacing
the leader.
For example, approximately three-fourths of the way through the first meeting of a
group for clients with bulimia, I asked for the members’ reflections on the meeting: How
had it gone for them? Disappointments? Surprises? One member, who was to control the
direction of the group for the next several weeks, commented that it had gone precisely as
she had expected; in fact, it had been almost disappointingly predictable. The strongest
feeling that she had had thus far, she added, was anger toward me because I had asked one
of the members a question that evoked a brief period of weeping. She had felt then,
“They’ll never break me down like that!” Her first impressions were very predictive of her
behavior for some time to come. She remained on guard and strove to be self-possessed
and in control at all times. She regarded me not as an ally but as an adversary and was
sufficiently forceful to lead the group into a major emphasis on control issues for the first
several sessions.
If therapy is to be successful, counterdependent members must at some point experience
their flip side and recognize and work through deep dependency cravings. The challenge
in their therapy is first to understand that their counterdependent behavior often evokes
rebuke and rejection from others before their wish to be nourished and protected can be
experienced or expressed.
Other members invariably side with the therapist. They must be helped to investigate
their need to defend the therapist at all costs, regardless of the issue involved.
Occasionally, clients defend you because they have encountered a series of unreliable
objects and misperceive you as extraordinarily frail; others need to preserve you because
they fantasize an eventual alliance with you against other powerful members of the group.
Beware that you do not unknowingly transmit covert signals of personal distress to which
the rescuers appropriately respond.
Many of these conflicted feelings crystallize around the issue of the leader’s name. Are
you to be referred to by professional title (Dr. Jones or, even more impersonally, the doctor
or the counselor) or by first name? Some members will immediately use the therapist’s
first name or even a diminutive of the name, before inquiring about the therapist’s
preference. Others, even after the therapist has wholeheartedly agreed to proceeding on a
first-name basis, still cannot bring themselves to mouth such irreverence and continue to
bundle the therapist up in a professional title. One client, a successful businessman who
had been consistently shamed and humiliated by a domineering father insisted on
addressing the therapist as “Doctor” because he claimed this was a way to ensure that he
was getting his money’s worth.

Although I have posited disenchantment and anger with the leader as a ubiquitous
feature of small groups, by no means is the process constant across groups in form or
degree. The therapist’s behavior may potentiate or mitigate both the experience and the
expression of rebellion. Thus, one prominent sociologist, who has for many years led
sensitivity-training groups of college students, reports that inevitably there is a powerful
insurrection against the leader, culminating in the members removing him or her bodily
from the group room.20 I, on the other hand, led similar groups for more than a decade and
never encountered a rebellion so extreme that members physically ejected me from the
room. Such a difference can be due only to differences in leader styles and behavior. What
kind of leader evokes the most negative responses? Generally it is those who are
ambiguous or deliberately enigmatic; those who are authoritative yet offer no structure or
guidelines; or those who covertly make unrealistic promises to the group early in
therapy.21
This stage is often difficult and personally unpleasant for group therapists. Let me
remind neophyte therapists that you are essential to the survival of the group. The
members cannot afford to liquidate you: you will always be defended. For your own
comfort, however, you must learn to discriminate between an attack on your person and an
attack on your role in the group. The group’s response to you is similar to transference
distortion in individual therapy in that it is not directly related to your behavior, but its
source in the group must be understood from both an individual psychodynamic and a
group dynamic viewpoint.
Therapists who are particularly threatened by a group attack protect themselves in a
variety of ways.†22 Once I was asked to act as a consultant for two therapy groups, each
approximately twenty-five sessions old, that had developed similar problems: both groups
seemed to have reached a plateau, no new ground appeared to have been broken for
several weeks, and the members seemed to have withdrawn their interest in the groups. A
study of current meetings and past protocols revealed that neither group had yet directly
dealt with any negative feelings toward the therapists. However, the reasons for this
inhibition were quite different in the two groups. In the first group, the two co-therapists
(first-time leaders) had clearly exposed their throats, as it were, to the group and, through
their obvious anxiety, uncertainty, and avoidance of hostility-laden issues, pleaded frailty.
In addition, they both desired to be loved by all the members and had been at all times so
benevolent and so solicitous that an attack by the group members would have appeared
unseemly and ungrateful.
The therapists of the second group had forestalled an attack in a different fashion: they
remained aloof, Olympian figures whose infrequent, ostensibly profound interventions
were delivered in an authoritarian manner. At the end of each meeting, they summarized,
often in unnecessarily complex language, the predominant themes and each member’s
contributions. To attack these therapists would have been both impious and perilous.
Therapist countertransference in these two instances obstructed the group’s work.
Placing one’s own emotional needs ahead of the group’s needs is a recipe for failure.23
Either of these two leadership styles tends to inhibit a group; suppression of important

ambivalent feelings about the therapist results in a counterproductive taboo that opposes
the desired norm of interpersonal honesty and emotional expression. Furthermore, an
important model-setting opportunity is lost. The therapist who withstands an attack
without being either destroyed or vindictive but instead responds by attempting to
understand and work through the sources and effects of the attack demonstrates to the
group that aggression need not be lethal and that it can be expressed and understood in the
group.
One of the consequences of suppression of therapist-directed anger for the two groups
in question, and for most groups, is the emergence of displaced, off-target aggression. For
example, one group persisted for several weeks in attacking doctors. Previous unfortunate
experiences with doctors, hospitals, and individual therapists were described in detail,
often with considerable group consensus on the injustices and inhumanity of the medical
profession. In one group, a member attacked the field of psychotherapy by bringing in a
Psychology Today article that purported to prove that psychotherapy is ineffective. At
other times, police, teachers, and other representatives of authority are awarded similar
treatment.
Scapegoating of other members is another off-target manifestation. It is highly
improbable for scapegoating to persist in a group in the absence of the therapist’s
collusion. The leader who cannot be criticized openly generally is the source of
scapegoating. Peer attack is a safer way of expressing aggression and rivalry or of
elevating one’s status in the group. Added to this dynamic is the group members’
unconscious need to project unacceptable aspects of self onto a group member in an
attempt to reduce the risk of personal rejection by the group. At its worst, this scapegoated
member can be sacrificed by the group under the covert and misguided belief that if only
it were not for this one member, the group would become a utopia.24
Yet another source of group conflict originates in the intrinsic process of change.
Rigidly entrenched attitudes and behavioral patterns are challenged by other members, and
each individual is faced with the discomfort of letting go of old patterns. A useful
paradigm of change in group work consists of the sequence of unfreezing, change, and
refreezing. 25 The stage of “unfreezing” naturally entails a degree of challenge and
conflict. Individuals adhere to their beliefs about relationships and cling to what is familiar
to them. At first many clients lack the ability to examine themselves and to accept
feedback. Gradually clients acquire the capacity to participate, feel emotion, and then
reflect on that experience. Once that is possible, harmful, habitual patterns of behavior can
be altered.26
The Third Stage: Development of Cohesiveness
A third commonly recognized formative phase of a group is the development of mature
group cohesiveness. After the previous period of conflict, the group gradually develops
into a cohesive unit. Many varied phrases with similar connotations have been used to

describe this phase: in-group consciousness;27 common goal and group spirit;28
consensual group action, cooperation, and mutual support;29 group integration and
mutuality; 30 we-consciousness unity;31 support and freedom of communication;32 and
establishment of intimacy and trust between peers.
In this phase the interpersonal world of the group is one of balance, resonance, safety,
increased morale, trust, and self-disclosure.33 Some members reveal the real reason they
have come for treatment: sexual secrets and long-buried transgressions are shared.
Postgroup coffee meetings may be arranged. Attendance improves, and clients evince
considerable concern about missing members.
The chief concern of the group is with intimacy and closeness. If we characterize
clients’ concerns in the first phase as “in or out” and the second as “top or bottom,” then
we can think of the third phase as “near or far.” The members’ primary anxieties have to
do with not being liked, not being close enough to others, or being too close to others.34
Although there may be greater freedom of self-disclosure in this phase, there may also
be communicational restrictions of another sort: often the group suppresses all expression
of negative affect in the service of cohesion. Compared with the previous stage of group
conflict, all is sweetness and light, and the group basks in the glow of its newly discovered
unity.35 Eventually, however, the glow will pale and the group embrace will seem
ritualistic unless differentiation and conflict in the group are permitted to emerge. Only
when all affects can be expressed and constructively worked through in a cohesive group
does the group become a mature work group—a state lasting for the remainder of the
group’s life, with periodic short-lived recrudescences of each of the earlier phases. Thus
one may think of the stage of growing cohesiveness as consisting of two phases: an early
stage of great mutual support (group against external world) and a more advanced stage of
group work or true teamwork in which tension emerges not out of the struggle for
dominance but out of each member’s struggle with his or her own resistances.
Overview
Now that I have outlined the early stages of group development, let me qualify my
statements lest the novice take the proposed developmental sequence too literally. The
developmental phases are in essence constructs—entities that exist for the group leaders’
semantic and conceptual convenience. Although the research shows persuasively, using
different measures, client populations, and formal change theories, that group
development occurs, the evidence is less clear on whether there is a precise, inviolate
sequence of development. At times the development appears linear; at other times it is
cyclical with a reiterative nature.36 It is also apparent that the boundaries between phases
are not clearly demarcated and that a group does not permanently graduate from one
phase.
Another approach to group development research is to track the course of particular
variables such as cohesion,37 emotionality,38 or intimacy39 through the course of the

group. No linear course exists. In considering group development, think of replacing an
automobile wheel: one tightens the bolts one after another just enough so that the wheel is
in place; then the process is repeated, each bolt being tightened in turn, until the wheel is
entirely secure. In the same way, phases of a group emerge, become dominant, and then
recede, only to have the group return to the same issues with greater thoroughness later.
Thus, it is more accurate to speak of developmental tasks rather than developmental
phases or a predictable developmental sequence. We may, for example, see a sequence of
high engagement and low conflict, followed by lower engagement and higher conflict,
followed by a return to higher engagement.40 Hamburg suggests the term cyclotherapy to
refer to this process of returning to the same issues but from a different perspective and
each time in greater depth.41 Often a therapy group will spend considerable time dealing
with dominance, trust, intimacy, fears, the relationship between the co-therapists, and then,
months later, return to the same topic from an entirely different perspective.
The group leader is well advised to consider not only the forces that promote the
group’s development, but also those that have been identified as antigroup.42 These
common forces encompass individual and societal resistance to joining—the fear of
merging; the fear of loss of one’s sense of independence; the loss of one’s fantasy of
specialness; the fear of seeking but being turned away.
THE IMPACT OF CLIENTS ON GROUP
DEVELOPMENT
The developmental sequence I have described perhaps accurately portrays the unfolding of
events in a theoretical, unpeopled therapy group and is much like the major theme of an
ultramodern symphony that is unintelligible to the untrained ear. In the group, obfuscation
derives from the richness and unpredictability of human interaction, which complicates
the course of treatment and yet contributes to its excitement and challenge.
My experience is that the development of therapy groups is heavily and invariably
influenced by chance—by the particular and unique composition of the group. Often the
course of the group is set by a single member, generally the one with the loudest
interpersonal pathology. By loudest I refer not to severity of pathology but to pathology
that is most immediately manifest in the group. For example, in the first meeting of a
group of incest victims, a member made a number of comments to the effect that she was
disappointed that so many members were present whose healing was at such an earlier
state than hers. Naturally, this evoked considerable anger from the others, who attacked
her for her condescending remarks. Before long this group developed into the angriest,
and least caring, group I’d ever encountered. We cannot claim that this one member put
anger into the group. It would be more accurate to say that she acted as a lightning rod to
release anger that was already present in each of the participants. But had she not been in
the group, it is likely that the anger may have unfolded more slowly, perhaps in a context

of more safety, trust, and cohesiveness. Groups that do not start well face a far more
difficult challenge than ones that follow the kind of developmental sequence described in
this chapter.
Many of the very individuals who seek group therapy struggle with relating and
engaging. That is often why they seek therapy. Many say of themselves, “I am not a group
person.”43 A group composed of several such individuals will doubtless struggle with the
group tasks more than a group containing several members who have had constructive and
effective experience with groups.44
Other individuals who may alter typical group developmental trends include those with
monopolistic proclivities, exhibitionism, promiscuous self-disclosure, or an unbridled
inclination to exert control. Not infrequently, such individuals receive covert
encouragement from the therapist and other group members. Therapists value these clients
because they provide a focus of irritation in the group, stimulate the expression of affect,
and enhance the interest and excitement of a meeting. The other members often initially
welcome the opportunity to hide behind the protagonist as they themselves hesitantly
examine the terrain.
In a study of the dropouts of nine therapy groups, I found that in five of them, a client
with a characteristic pattern of behavior fled the therapy group within the first dozen
meetings.45 These clients (“early provocateurs”) differed from one another dynamically
but assumed a similar role in the group: They stormed in, furiously activated the group,
and then vanished. The therapists described their role in the group in such terms as
“catalysts,” “targets,” “hostile interpreters,” or “the only honest one.” Some of these early
provocateurs were active counterdependents and challenged the therapist early in the
group. One, for example, challenged the leader in the third meeting in several ways: he
suggested that the members hold longer meetings and regular leaderless meetings, and,
only half jokingly, tried to launch an investigation into the leader’s personal problems.
Other provocateurs prided themselves on their honesty and bluntness, mincing no words in
giving the other members candid feedback. Still others, heavily conflicted in intimacy,
both seeking it and fearing it, engaged in considerable self-disclosure and exhorted the
group to reciprocate, often at a reckless pace. Although the early provocateurs usually
claimed that they were impervious to the opinions and evaluations of others, in fact they
cared very much and, in each instance, deeply regretted the nonviable role they had
created for themselves in the group.46
Therapists must recognize this phenomenon early in the group and, through clarification
and interpretation of their role, help prevent these individuals from committing social
suicide. Perhaps even more important, therapists must recognize and discontinue their own
covert encouragement of the early provocateur’s behavior. It is not uncommon for
therapists to be stunned when the early provocateur drops out. They may so welcome the
behavior of these clients that they fail to appreciate the client’s distress as well as their
own dependence on these individuals for keeping the group energized.
It is useful for therapists to take note of their reactions to the absence of the various
members of the group. If some members are never absent, you may fantasize their

absences and your reaction to it. Consider what thoughts, feelings, fantasies and actions
these individuals generate in you, and what they do to generate that impact.47 If you dread
the absence of certain members, feeling that there would be no life in the group that day,
then it is likely that there is too much burden on those individuals and so much secondary
gratification that they will not be able to deal with their primary task in therapy. Given the
responsibility projected onto them, they may well be considered a form of scapegoat,
although a positively viewed one, at least at first.ab
I believe much of the confusion about group development is that each group is, at the
same time, like all groups, like some groups, and like no other group! Of course, all
therapy groups go through some change as they proceed. Of course there is some early
awkwardness, as the group deals with its raison d’être and its boundaries. Of course this is
followed by some tension and by repeated attempts to develop intimacy. And of course all
groups must face termination—the final phase. And from time to time, but only from time
to time, one encounters a group that runs “on schedule.”
Some time ago at an A. K. Rice two-week group workshop, I took part in an intergroup
exercise in which the sixty participants were asked to form four groups in any manner they
wished and then to study the ongoing relationships among the groups. The sixty
participants, in near panic, stampeded from the large room toward the four rooms
designated for the four small groups. The panic, an inevitable part of this exercise,
probably stemmed from primitive fears of exclusion from a group.48 In the group in which
I participated, the first words spoken after approximately sixteen members had entered the
room were, “Close the door. Don’t let anyone else in!” The first act of the group was to
appoint an official doorkeeper. Once the group’s boundaries were defined and its identity
vis-à-vis the outside world established, the group turned its attention to regulating the
distribution of power by speedily electing a chairman, before multiple bids for leadership
could immobilize the group. Only later did the group experience and discuss feelings of
trust and intimacy and then, much later, feelings of sadness as the group approached
termination.
In summary, there are some advantages to group therapists’ possessing some broad
schema of a group developmental sequence: It enables them to maintain objectivity and to
chart the voyage of a group despite considerable yawing, and to recognize if a group never
progresses past a certain stage or omits some. At times, therapists may demand something
for which the group is not yet ready: mutual caring and concern develop late in the group;
in the beginning, caring may be more pro forma as members view one another as
interlopers or rivals for the healing touch of the therapist. The therapist who is aware of
normative group development is able to remain more finely tuned to the group.
But there is a downside to the clinical application of group developmental ideas. The
inexperienced therapist may take them too seriously and use them as a template for
clinical practice. I have seen beginning therapists exert energy on forcing a group, in
procrustean fashion, to progress in lockstep through set phases. Such formulaic therapy—
and it grows more common in these days of standardized therapy via treatment manual—
lessens the possibility of real therapist-client engagement. The sacrifice of realness, of

authenticity, in the therapeutic relationship is no minor loss: It is the loss of the very heart
of psychotherapy.
Certainly, the first generations of psychotherapy manuals diminished the authenticity of
therapy by their slavish attention to adherence to the model. More contemporary therapy
manuals do less micromanaging of treatment and provide more scope for therapist
flexibility and naturalness.49
Psychotherapy, whether with a group or with an individual client, should be a shared
journey of discovery. There is danger in every system of “stages”—in the therapist having
fixed, preconceived ideas and procedural protocols in any kind of growth-oriented therapy.
It is precisely for this reason that some trends forced on the field by managed care are so
toxic.
In the mid-1970s, I began the first group for cancer patients with Katy Weers, a
remarkable woman with advanced breast cancer. She often railed about the harm brought
to the field by Elisabeth Kübler-Ross’s “stages” of dying, and dreamed of writing a book
to refute this concept. To experience the client against a template of stages interferes with
the very thing so deeply desired by clients: “therapeutic presence.” Katy and I both
suspected that therapists cloaked themselves in the mythology of “stages” to muffle their
own death anxiety.
MEMBERSHIP PROBLEMS
The early developmental sequence of a therapy group is powerfully influenced by
membership problems. Turnover in membership, tardiness, and absence are facts of life in
the developing group and often threaten its stability and integrity. Considerable
absenteeism may redirect the group’s attention and energy away from its developmental
tasks toward the problem of maintaining membership. It is the therapist’s task to
discourage irregular attendance and, when necessary, to replace dropouts appropriately by
adding new members.
Turnover
In the normal course of events, a substantial number of members drop out of
interactionally based groups in the first twelve meetings (see table 8.1). If two or more
members drop out, new members are usually added—but often a similar percentage of
these additions drop out in their first dozen or so meetings. Only after this does the group
solidify and begin to engage in matters other than those concerning group stability.
Generally, by the time clients have remained in the group for approximately twenty
meetings, they have made the necessary long-term commitment. In an attendance study of
five groups, there was considerable turnover in membership within the first twelve

meetings, a settling in between the twelfth and twentieth, and near-perfect attendance,
with excellent punctuality and no dropouts, between the twentieth and forty-fifth meetings
(the end of the study).50 Most studies demonstrate the same findings.51 It is unusual for the
number of later dropouts to exceed that of earlier phases.52 In one study in which attrition
in later phases was higher, the authors attributed the large numbers of later dropouts to
mounting discomfort arising from the greater intimacy of the group. Some groups had a
wave of dropouts; one dropout seemed to seed others. As noted in chapter 8, prior or
concurrent individual therapy substantially reduces the risk of premature termination.53
In general, short-term groups report lower dropout rates.54 In closed, time-limited
groups, it is useful to start with a large enough number of clients that the group can
withstand some attrition and yet be sufficiently robust for the duration of the group’s
course. Too large a starting size invites dropouts from individuals who will feel detached
and peripheral to the group. Starting with nine or ten members is probably ideal in this
situation.
Attendance and Punctuality
Despite the therapist’s initial encouragement of regular attendance and punctuality,
difficulties usually arise in the early stages of a group. At times the therapist, buffeted by
excuses from clients—baby-sitting problems, vacations, transportation difficulties, work
emergencies, out-of-town guests—becomes resigned to the impossibility of synchronizing
the schedules of eight busy people. Resist that course! Tardiness and irregular attendance
usually signify resistance to therapy and should be regarded as they are in individual
therapy. When several members are often late or absent, search for the source of the group
resistance; for some reason, cohesiveness is limited and the group is foundering. If a group
solidifies into a hard-working cohesive group, then—mirabile dictu—the baby-sitting and
scheduling problems vanish and there may be perfect attendance and punctuality for many
months.
At other times, the resistance is individual rather than group based. I am continually
amazed by the transformation in some individuals, who for long periods have been tardy
because of “absolutely unavoidable” contingencies—for example, periodic business
conferences, classroom rescheduling, child care emergencies—and then, after recognizing
and working through the resistance, become the most punctual members for months on
end. One periodically late member hesitated to involve himself in the group because of his
shame about his impotence and homosexual fantasies. After he disclosed these concerns
and worked through his feelings of shame, he found that the crucial business commitments
responsible for his lateness—commitments that, he later revealed, consisted of perusing
his mail—suddenly evaporated.
Whatever the basis for resistance, it is behavior that must, for several reasons, be
modified before it can be understood and worked through. For one thing, irregular
attendance is destructive to the group. It is contagious and leads to group demoralization.

Obviously, it is impossible to work on an issue in the absence of the relevant members.
Few exercises are more futile than addressing the wrong audience by deploring irregular
attendance with the group members who are present—the regular, punctual participants.
Groups are generally supportive of individuals who are genuinely trying to attend
regularly but fall short, in contrast to their intolerance of those who lack real commitment
to the group.
Various methods of influencing attendance have been adopted by therapists. During
pretherapy interviews, many therapists stress the importance of regular attendance. Clients
who appear likely to have scheduling or transportation problems are best referred for
individual therapy, as are those who must be out of town once a month or who, a few
weeks after the group begins, plan an extended out-of-town vacation. Charging full fees
for missed sessions is standard practice. Many private practitioners set a fixed monthly
fee, which is not reduced for missed meetings for any reason.
There are few more resistant group clients than men who have physically abused their
partners. At the same time, there is robust evidence that group interventions are effective
with this population, if the men continue in treatment. However, dropout rates of 40–60
percent within three months are not uncommon. Clinicians working with this population
have tackled the problem of poor motivation directly with intensive pregroup training,
including psychoeducational videos to increase empathy for the victims and inform
abusers about the physiology and psychology of violence. 55 An even simpler intervention
has proven powerfully effective. In a study of 189 men, group leaders who reached out
actively via phone calls, expressions of concern, and personalized alliance-building
measures produced dramatic results. These simple, low-tech interventions significantly
increased both attendance and tenure in both interpersonal and cognitive-behavioral group
therapies and significantly reduced the incidence of domestic violence.56
It is critical that the therapist be utterly convinced of the importance of the therapy
group and of regular attendance. The therapist who acts on this conviction will transmit it
to the group members. Thus, therapists should arrive punctually, award the group high
priority in their own schedule, and, if they must miss a meeting, inform the group of their
absence weeks in advance. It is not uncommon to find that therapist absence or group
cancellation may be followed by poor attendance.
• Upon arriving at a psychotherapy group for elderly men, I discovered that half
the group of eight was absent. Illness, family visits, and conflicting appointments
all conspired to diminish turnout. As I surveyed the room strewn with empty chairs,
one man spoke up and suggested with some resignation that we cancel the group
since so many members were away. My first reaction was one of quiet relief at the
prospect of unexpected free time in my day. My next thought was that canceling the
meeting was a terrible message to those present. In fact, the message would echo
the diminishment, isolation, and unwantedness that the men felt in their lives.
Therefore I suggested that it might be even more important than ever to meet today.
The men actively embraced my comment as well as my suggestion that we remove
the unnecessary chairs and tighten the circle so that we could hear one another

better.
A member who has a poor attendance record (whatever the reason) is unlikely to benefit
from the group. In a study of ninety-eight group participants, Stone and his colleagues
found that poor attendance early in the group was linearly related to late dropout (at six to
twelve months).57 Thus, inconsistent attendance demands decisive intervention.
• In a new group, one member, Dan, was consistently late or absent. Whenever the
co-therapists discussed his attendance, it was clear that Dan had valid excuses: his
life and his business were in such crisis that unexpected circumstances repeatedly
arose to make attendance impossible. The group as a whole had not jelled; despite
the therapists’ efforts, other members were often late or absent, and there was
considerable flight during the sessions. At the twelfth meeting, the therapists
decided that decisive action was necessary. They advised Dan to leave the group,
explaining that his schedule was such that the group could be of little value to him.
They offered to help Dan arrange individual therapy, which would provide greater
scheduling flexibility. Although the therapists’ motives were not punitive and
although they were thorough in their explanation, Dan was deeply offended and
walked out in anger midway through the meeting. The other members, extremely
threatened, supported Dan to the point of questioning the therapists’ authority to
ask a member to leave.
Despite the initial, raucous reaction of the group, it was soon clear that the
therapists had made the proper intervention. One of the co-therapists phoned Dan
and saw him individually for two sessions, then referred him to an appropriate
therapist for individual therapy. Dan soon appreciated that the therapists were
acting not punitively but in his best interests: irregularly attending a therapy group
would not have been effective therapy for him. The group was immediately
affected: attendance abruptly improved and remained near perfect over the next
several months. The members, once they had recovered from their fear of similar
banishment, gradually disclosed their approval of the therapists’ act and their
great resentment toward Dan and, to a lesser extent, toward some of the other
members for having treated the group in such a cavalier fashion.
Some therapists attempt to improve attendance by harnessing group pressure—for
example, by refusing to hold a meeting until a predetermined number of members (usually
three or four) are present. Even without formalization of this sort, the pressure exerted by
the rest of the group is an effective lever to bring to bear on errant members. The group is
often frustrated and angered by the repetitions and false starts necessitated by irregular
attendance. The therapist should encourage the members to express their reactions to late
or absent members. Be mindful, though, that the therapist’s concern about attendance is
not always shared by the members: a young or immature group often welcomes the small
meeting, regarding it as an opportunity for more individual attention from the leader.
Similarly, be cautious not to punish the regular participants by withholding treatment in
the process of applying group pressure on the absent members.
Like any event in the group, absenteeism or tardiness is a form of behavior that reflects

an individual’s characteristic patterns of relating to others. Be sure to examine the personal
meaning of the client’s action. If Mary arrives late, does she apologize? Does Joe enter in
a thoughtless, exhibitionistic manner? Does Sally arrive late because she experiences
herself as nonentity who makes no contribution to the group’s life in any event? Does
Ralph come as he chooses because he believes nothing of substance happens without him
anyway? Does Peg ask for a recap of the events of the meeting? Is her relation with the
group such that the members provide her with a recap? If Stan is absent, does he phone in
advance to let the group know? Does he offer complex, overelaborate excuses, as though
convinced he will not be believed? Not infrequently, a client’s psychopathology is
responsible for poor attendance. For example, one man who sought therapy because of a
crippling fear of authority figures and a pervasive inability to assert himself in
interpersonal situations was frequently late because he was unable to muster the courage
to interrupt a conversation or a conference with a business associate. An obsessive-
compulsive client was late because he felt compelled to clean his desk over and over
before leaving his office.
Thus, absenteeism and lateness are part of the individual’s social microcosm and, if
handled properly, may be harnessed in the service of self-understanding. For both the
group’s and the individual’s sake, however, they must be corrected before being analyzed.
No interpretation can be heard by an absent group member. In fact, the therapist must
attend to the timing of his comments to the returning member. Clients who have been
absent or are late often enter the meeting with some defensive guilt or shame and are not
in an optimal state of receptiveness for observations about their behavior. The therapist
does well to attend first to group maintenance and norm-setting tasks and then, later, when
the timing seems right and defensiveness diminished, attempt to help the individual
explore the meaning of his or her behavior. The timing of feedback is particularly
important for members who have greater psychological vulnerability and less mature
relationships.58
Group members who must miss a meeting or arrive late should, as they were advised in
pregroup preparation, phone the therapist in advance in order to spare the group from
wasting time expressing curiosity or concern about their absence. Often, in advanced
groups, the fantasies of group members about why someone is absent provide valuable
material for the therapeutic process; in early groups, however, such speculations tend to be
superficial and unfruitful.
An important adage of interactional group therapy, which I emphasize many times
throughout this book, is that any event in the group can serve as grist for the interpersonal
mill. Even the absence of a member can generate important, previously unexplored
material.
• A group composed of four women and three men held its eighth meeting in the
absence of two of the men. Albert, the only male present, had previously been
withdrawn and submissive in the group, but in this meeting a dramatic
transformation occurred. He erupted into activity, talked about himself, questioned
the other members, spoke loudly and forcefully, and, on a couple of occasions,

challenged the therapist. His nonverbal behavior was saturated with quasi-
courtship bids directed at the women members: for example, frequent adjustment
of his shirt collar and preening of the hair at his temples. Later in the meeting, the
group focused on Albert’s change, and he realized and expressed his fear and envy
of the two missing males, both of whom were aggressive and assertive. He had
long experienced a pervasive sense of social and sexual impotence, which had
been reinforced by his feeling that he had never made a significant impact on any
group of people and especially any group of women. In subsequent weeks, Albert
did much valuable work on these issues—issues that might not have become
accessible for many months without the adventitious absence of the two other
members.
My clinical preference is to encourage attendance but never, regardless of how small the
group is, to cancel a session. There is considerable therapeutic value in the client’s
knowing that the group is always there, stable and reliable: its constancy will in time beget
constancy of attendance. I have led many small group sessions, with as few as two
members, that have proved to be critical for those attending. The technical problem with
such meetings is that without the presence of interaction, the therapist may revert to
focusing on intrapsychic processes in a manner characteristic of individual therapy and
forgo group and interpersonal issues. It is far more therapeutically consistent to focus in
depth on group and interpersonal processes even in the smallest of sessions. Consider the
following clinical example from a ten-month-old group:
• For various reasons—vacations, illnesses, resistance—only two members
attended: Wanda, a thirty-eight-year-old depressed woman with borderline
personality disorder who had twice required hospitalization, and Martin, a twenty-
three-year-old man with schizoid personality disorder who was psychosexually
immature and suffered from moderately severe ulcerative colitis.
Wanda spent much of the early part of the meeting describing the depth of her
despair, which during the past week had reached such proportions that she had
been preoccupied with suicide and, since the group therapist was out of town, had
visited the emergency room at the hospital. While there, she had surreptitiously
read her medical chart and seen a consultation note written a year earlier by the
group therapist in which he had diagnosed her as borderline. She said that she had
been anticipating this diagnosis and now wanted the therapist to hospitalize her.
Martin then recalled a fragment of a dream he had several weeks before but had
not discussed: the therapist was sitting at a large desk interviewing Martin, who
stood up and looked at the paper on which the therapist is writing. There he saw in
huge letters one word covering the entire page: IMPOTENT. The therapist helped
both Wanda and Martin discuss their feelings of awe, helpless dependence, and
resentment toward him as well as their inclination to shift responsibility and
project onto him their bad feelings about themselves.
Wanda proceeded to underscore her helplessness by describing her inability to
cook for herself and her delinquency in paying her bills, which was so extreme that

she now feared police action against her. The therapist and Martin both discussed
her persistent reluctance to comment on her positive accomplishments—for
example, her continued excellence as a teacher. The therapist wondered whether
her presentation of herself as helpless was not designed to elicit responses of
caring and concern from the other members and the therapist—responses that she
felt would be forthcoming in no other way.
Martin then mentioned that he had gone to the medical library the previous day
to read some of the therapist’s professional articles. In response to the therapist’s
question about what he really wanted to find out, Martin answered that he guessed
he really wanted to know how the therapist felt about him and proceeded to
describe, for the first time, his longing for the therapist’s sole attention and love.
Later, the therapist expressed his concern at Wanda’s reading his note in her
medical record. Since there is a realistic component to a client’s anxiety on
learning that her therapist has diagnosed her as borderline, the therapist candidly
discussed both his own discomfort at having to use diagnostic labels for hospital
records and the confusion surrounding psychiatric nosological terminology; he
recalled as best he could his reasons for using that particular label and its
implications.
Wanda then commented on the absent members and wondered whether she had
driven them from the group (a common reaction). She dwelled on her unworthiness
and, at the therapist’s suggestion, made an inventory of her baleful characteristics,
citing her slovenliness, selfishness, greed, envy, and hostile feelings toward all
those in her social environment. Martin both supported Wanda and identified with
her, since he recognized many of these feelings in himself. He discussed how
difficult it was for him to reveal himself in the group (Martin had disclosed very
little of himself previously in the group). Later, he discussed his fear of getting
drunk or losing control in other ways: for one thing, he might become indiscreet
sexually. He then discussed, for the first time, his fear of sex, his impotence, his
inability to maintain an erection, and his last-minute refusals to take advantage of
sexual opportunities. Wanda empathized deeply with Martin and, although she had
for some time regarded sex as abhorrent, expressed the strong wish (a wish, not an
intention) to help him by offering herself to him sexually. Martin then described his
strong sexual attraction to her, and later both he and Wanda discussed their sexual
feelings toward the other members of the group. The therapist made the
observation, one that proved subsequently to be of great therapeutic importance to
Wanda, that her interest in Martin and her desire to offer herself to him sexually
belied many of the items in her inventory: her selfishness, greed, and ubiquitous
hostility to others.
Although only two members were present at this meeting, they met as a group and not
as two individual clients. The other members were discussed in absentia, and previously
undisclosed interpersonal feelings between the two clients and toward the therapist were
expressed and analyzed. It was a valuable session, deeply meaningful to both participants.

It is worth noting here that talking about group members in their absence is not “talking
behind people’s backs.” A member’s absence cannot dictate what gets addressed by those
in attendance, although it is essential that absent members be brought back into the loop
upon their return. Mailing out a group summary (see chapter 14) is a good way to
accomplish this.
Dropouts
There is no more threatening problem for the neophyte group therapist (and for many
experienced therapists as well) than the dropout from group therapy. Dropouts concerned
me greatly when I first started to lead groups, and my first group therapy research was a
study of all the group participants who had dropped out of the therapy groups in a large
psychiatric clinic.59 It is no minor problem. As I discussed earlier, the group therapy
demographic research demonstrates that a substantial number of clients will leave a group
prematurely regardless of what the therapist does. In fact, some clinicians suggest that
dropouts are not only inevitable but necessary in the sifting process involved in achieving
a cohesive group.60
Consider, too, that the existence of an escape hatch may be essential to allow some
members to make their first tentative commitments to the group. The group must have
some decompression mechanism: mistakes in the selection process are inevitable,
unexpected events occur in the lives of new members, and group incompatibilities
develop. Some intensive weeklong human relations laboratories or encounter groups that
meet at a geographically isolated place lack a way of escape; on several occasions, I have
seen psychotic reactions in participants forced to continue in an incompatible group.
There are various reasons for premature termination (see chapter 8). It is often
productive to think about the dropout phenomenon from the perspective of the interaction
of three factors: the client, the group, and the therapist.61 In general, client contributions
stem from problems caused by deviancy, conflicts in intimacy and disclosure, the role of
the early provocateur, external stress, complications of concurrent individual and group
therapy, inability to share the leader, and fear of emotional contagion. Underlying all these
reasons is the potential stress early in the group. Individuals who have maladaptive
interpersonal patterns are exposed to unaccustomed demands for candor and intimacy;
they are often confused about procedure; they suspect that the group activities bear little
relevance to their problem; and, finally, they feel too little support in the early meetings to
sustain their hope.
Group factors include the consequences of subgrouping, poor compositional match of
clients, scapegoating, member-member impasses, or unresolved conflict. The therapists
also play a role: they may select members too hurriedly, they may not prepare members
adequately, they may not attend to building group cohesion, or they may be influenced by
unresolved countertransference reactions.

Preventing Dropouts. As I discussed earlier, the two most important methods of
decreasing the dropout rate are proper selection and comprehensive pretherapy
preparation. It is especially important that in the preparation procedure, the therapist make
it clear that periods of discouragement are to be expected in the therapy process. Clients
are less likely to lose confidence in a therapist who appears to have the foreknowledge that
stems from experience. In fact, the more specific the prediction, the greater its power. For
example, it may be reassuring to a socially anxious and phobic individual to anticipate that
there will be times in the group when he will wish to flee, or that he will dread coming to
the next meeting. The therapist can emphasize that the group is a social laboratory and
suggest that the client has the choice of making the group yet another instance of failure
and avoidance or, for the first time, staying in the group and experimenting, in a low-risk
situation, with new behaviors. Some groups contain experienced group members who
assume some of this predictive function, as in the following case:
• One group graduated several members and was reconstituted by adding five new
members to the remaining three veteran members. In the first two meetings, the old
members briefed the new ones and told them, among other things, that by the sixth
or seventh meeting some member would decide to drop out and then the group
would have to drop everything for a couple of meetings to persuade him to stay.
The old members went on to predict which of the new members would be the first
to decide to terminate. This form of prediction is a most effective manner of
ensuring that it is not fulfilled.
Despite painstaking preparation, however, many clients will consider dropping out.
When a member informs a therapist that he or she wishes to leave the group, a common
approach is to urge the client to attend the next meeting to discuss it with the other group
members. Underlying this practice is the assumption that the group will help the client
work through resistance and thereby dissuade him or her from terminating. This approach,
however, is rarely successful. In one study of thirty-five dropouts from nine therapy
groups (with a total original membership of ninety-seven clients), I found that every one of
the dropouts had been urged to return for another meeting, but not once did this final
session avert premature termination.62 Furthermore, there were no group continuers who
had threatened to drop out and were salvaged by this technique, despite considerable
group time spent in the effort. In short, asking the client who has decided to drop out to
return for a final meeting is usually an ineffective use of group time.
Generally, the therapist is well advised to see a potential dropout for a short series of
individual interviews to discuss the sources of group stress. Occasionally an accurate,
penetrating interpretation will keep a client in therapy.
• Joseph, an alienated client with schizoid personality disorder, announced in the
eighth meeting that he felt he was getting nowhere in the group and was
contemplating termination. In an individual session, he told the therapist
something he had never been able to say in the group—namely, that he had many
positive feelings toward a couple of the group members. Nevertheless, he insisted
that the therapy was ineffective and that he desired a more accelerated and precise

form of therapy. The therapist correctly interpreted Joseph’s intellectual criticism
of the group therapy format as a rationalization: he was, in fact, fleeing from the
closeness he had felt in the group. The therapist again explained the social
microcosm phenomenon and clarified for Joseph that in the group he was
repeating his lifelong style of relating to others. He had always avoided or fled
intimacy and no doubt would always do so in the future unless he stopped running
and allowed himself the opportunity to explore his interpersonal problems in vivo.
Joseph continued in the group and eventually made considerable gains in therapy.
In general the therapist can decrease premature termination by attending assiduously to
early phase problems. I will have much to say later in this text about self-disclosure, but
for now keep in mind that outliers—excessively active members and excessively quiet
members—are both dropout risks. Try to balance self-disclosure. It may be necessary to
slow the pace of a client who too quickly reveals deeply personal details before
establishing engagement. On the other hand, members who remain silent session after
session may become demoralized and increasingly frightened of self-disclosure.
Negative feelings, misgivings, and apprehensions about the group or the therapeutic
alliance must be addressed and not pushed underground. Moreover, the expression of
positive affects should also be encouraged and, whenever possible, modeled by the
therapist.63
Inexperienced therapists are particularly threatened by the client who expresses a wish
to drop out. They begin to fear that, one by one, their group members will leave and that
they will one day come to the group and find themselves alone in the room. (And what,
then, do they tell their group supervisor?) Therapists for whom this fantasy truly takes
hold cease to be therapeutic to the group. The balance of power shifts. They feel
blackmailed. They begin to be seductive, cajoling—anything to entice the clients back to
future meetings. Once this happens, of course, any therapeutic leverage is lost entirely.
After struggling in my own clinical work with the problem of group dropouts over
many years, I have finally achieved some resolution of the issue. By shifting my personal
attitude, I no longer have group therapy dropouts. But I do have group therapy throwouts!
I do not mean that I frequently ask members to leave a therapy group, but I am perfectly
prepared to do so if it is clear that the member is not working in the group. I am persuaded
(from my clinical experience and from empirical research findings) that group therapy is a
highly effective mode of psychotherapy. If an individual is not going to be able to profit
from it, then I want to get that person out of the group and into a more appropriate mode
of therapy , and bring someone else into the group who will be able to use what the group
has to offer.
This method of reducing dropouts is more than a specious form of bookkeeping; it
reflects a posture of the therapist that increases the commitment to work. Once you have
achieved this particular mental set, you communicate it to your clients in direct and
indirect ways. You convey your confidence in the therapeutic modality and your
expectation that each client will use the group for effective work.

Removing a Client from a Group. Taking a client out of a therapy group is an act of
tremendous significance for both that individual and the group. Hence it must be
approached thoughtfully. Once a therapist determines that a client is not working
effectively, the next step is to identify and remove all possible obstacles to the client’s
productive engagement in the group. If the therapist has done everything possible yet is
still unable to alter the situation, there is every reason to expect one of the following
outcomes: (1) the client will ultimately drop out of the group without benefit (or without
further benefit); (2) the client may be harmed by further group participation (because of
negative interaction or the adverse consequences of the deviant role—see chapter 8); or
(3) the client will substantially obstruct the group work for the remaining group members.
Hence, it is folly to adopt a laissez-faire posture: the time has come to remove the client
from the group.
How? There is no adroit, subtle way to remove a member from a group. Often the task
is better handled in an individual meeting with the client than in the group. The situation is
so anxiety-provoking for the other members that generally the therapist can expect little
constructive group discussion; moreover, an individual meeting reduces the member’s
public humiliation. It is not helpful to invite the client back for a final meeting to work
things through with the group: if the individual were able to work things through in an
open, nondefensive manner, there would have been no need to ask him or her to leave the
group in the first place. In my experience, such final working-through meetings are
invariably closed, nonproductive, and frustrating.
Whenever you remove a client from the group, you should expect a powerful reaction
from the rest of the group. The ejection of a group member stirs up deep levels of anxiety
associated with rejection or abandonment by the primal group. You may get little support
from the group, even if there is unanimous agreement among the members that the client
should have been asked to leave. Even if, for example, the client had developed a manic
reaction and was disrupting the entire group, the members will still feel threatened by your
decision.
There are two possible interpretations the members may give to your act of removing
the member. One interpretation is rejection and abandonment: that is, that you do not like
the client, you resent him, you’re angry, and you want him out of the group and out of
your sight. Who might be next?
The other interpretation (the correct one, let us hope) is that you are a responsible
mental health professional acting in the best interests of that client and of the remaining
group members. Every individual’s treatment regimen is different, and you made a
responsible de