Therapeutic factors common to all groups

Irvin D. Yalom, one of the most noted researchers on group psychotherapy, is credited with identifying the factors that make groups therapeutic (Yalom & Leszcz, 2005). Therapeutic factors (Box 33-2) are aspects of the group experience that leaders and members have identified as curative and facilitative of therapeutic change. For example, as group members begin to share life experiences, feelings, and concerns, they may recognize for the first time that they are not “alone in the world,” which allows them to genuinely connect with others. Yalom calls this factor universality—the patient’s recognition that other persons feel the same way or have had the same experiences. Recognizing universality can provide a profound sense of relief. Different factors may overlap and operate at different phases of a group. The leader may role-model several therapeutic behaviors during the initial phase, such as instilling hope and imparting information. Just as with other types of treatment, each person’s response to a group is highly individualized based on past experiences and level of participation.

Planning a group

To develop a successful group, planning should include a description of specific characteristics, including the following:

Planning and structure are especially important when group leaders are likely to change (in inpatient settings where staffing patterns change) or when several groups are running concurrently with a common goal (in a research study), where consistency is most advantageous.

Thoughtful configuration of the physical space in which the group will meet is essential for promotion of comfort and function. Depending on the size of the group, the room and its physical boundaries should be organized with seats relatively close to each other in a nonhierarchical arrangement. Arranging chairs in a circle conveys equality among all present, whether a group member or leader, and allows for all members to see the whole group.

Basic comfort and sensory measures, such as room temperature, lighting, external noise, and privacy, should be optimized. Size of the room should be functional, as a huge room for a small group does not encourage intimacy, and an overcrowded room may contribute to discomfort and anxiety among members. It is also important to note that inpatient groups have significant differences from outpatient groups (Table 33-1), and the group planning must be adapted accordingly.

Phases of group development

All groups go through developmental phases similar to those identified for individual therapeutic relationships (refer to Chapter 8). In each phase, the group leader has specific roles and challenges to address in support of positive interaction, growth, and change.

In the orientation phase, the group is forming. The group leader’s role is to structure an atmosphere of respect, confidentiality, and trust. The purpose of the group is stated, and members are encouraged to get to know one another. Initially, members may be overly silent or overbearing because they have not yet established trust with one another. Therapeutic interaction is supported when the group leader points out similarities between members, encourages them to talk directly to each other rather than to the leader, and reminds members about ground rules for respectful, meaningful interaction.

In the working phase, the group leader’s role is to encourage a focus on problem solving that is consistent with the purpose of the group. As group members begin to feel safe within the group, conflicts may be expressed, which should be viewed by the group leader as a positive opportunity for group growth. It is important for the leader to guide and support conflict resolution. Through successful resolution of conflicts, group members are empowered to develop confidence in their problem-solving abilities and better support one another in their individual efforts to grow and change. Tuckman (1965) outlined this working phase of groups with classic stages of “storming, norming, and performing.” These collaborations generate group cohesion, followed by completion of group tasks, resulting in insight development.

In the termination phase, the group leader’s role is to encourage members to reflect on progress they have made and identify post termination goals. Members may experience feelings of loss or anger about the group”s ending; at times, these feelings can be directed toward other group members or the leader. It is important to openly address such feelings as part of the work toward successful group adjournment.

Group member roles

We each have a unique style of interacting with others, and we gravitate toward personal comfort zones within groups. Consider your own behaviors within groups. You may tend to sit back and mainly observe, giving your opinion only after careful consideration, or perhaps you feel it is important to keep everyone moving in a common direction or to help maintain order and actively urge people to continue working. The way we behave in groups is a function of our innate personalities (e.g., shy or outgoing), socialization (e.g., birth order, prior exposure to groups), and the specific context of the group (e.g., familiar and interesting topic or one outside of your comfort zone).

Studies of group dynamics have identified informal roles that group members often assume, which may or may not be helpful in the group’s development. The classic descriptive categories for these roles are task, maintenance, and individual roles (Benne & Sheats, 1948). Task roles keep the group focused on its main purpose and get the work done. Maintenance roles keep the group together, help each person feel worthwhile and included, and create a sense of group cohesion. There are also individual roles that have nothing to do with helping the group but instead relate to specific personalities, personal agendas, and desires for having needs met by shifting the group’s focus to them. Awareness of roles that individual members assume can assist the group leader in identifying behaviors that need to be reinforced or confronted. Members’ self-awareness of their roles may encourage more deliberate and insightful group participation. Table 33-2 describes the informal roles of group members.

The group leader has multiple responsibilities in initiating, maintaining, and terminating a group. The leader is often most commanding during the orientation phase. Here, the structure, size, composition, purpose, and timing of the group are defined. Task and maintenance functions may be introduced and demonstrated. During the working phase, the leader facilitates communication, the flow of group processes, and group conduct. In the termination phase, the leader ensures that each member summarizes individual accomplishments and insights and gives positive and negative feedback regarding the group experience.

Sensitivity to cultural diversity and cultural needs of individual members is a key responsibility of the group leader. The leader initially sets a foundation for open communication by defining the importance of mutual respect and rules for group conduct. As group members begin to engage with one another, the leader’s sensitivity to issues that may have a cultural basis can be pivotal in facilitating efforts to maintain open, respectful communication. Diversity exists in many forms, including racial, ethnic, economic, and sexual orientation. Encouraging members to share and explore their cultural foundations and beliefs promotes genuine, rich communication and provides the group with the opportunity to explore similarities and differences in a safe environment.

Consider the example of a woman who came to group after a significant suicide attempt. She remained silent and withdrawn until the leader encouraged her to explore her feelings about the group. The patient revealed that she “wasn’t smart like everyone else” and that she was “basically just trailer trash.” Other group members began to share their similarities and differences in backgrounds, with a focus on their common needs, fears, and insecurities. When this woman finished the group, she acknowledged having learned an important lesson: she could give and get help from persons she saw as different from her, and not everyone would treat her as if she were “unworthy.”

Styles of leadership

There are three main styles of group leadership, and a leader selects the style that is best suited to the therapeutic needs of a particular group. The autocratic leader exerts control over the group and does not encourage much interaction among members. For example, staff leading a community meeting with a fixed, time-limited agenda may tend to be more autocratic. In contrast, the democratic leader supports extensive group interaction in the process of problem solving. Psychotherapy groups most often employ this empowering leadership style. A laissez-faire leader allows the group members to behave in any way they choose and does not attempt to control the direction of the group. In a creative group, such as an art or horticulture group, the leader may choose a flexible laissez-faire style, directing minimally to allow for a variety of responses. In any group, the leader must be thoughtful about communication techniques since these can have a tremendous impact on group content and process. Table 33-3 describes communication techniques frequently used by group leaders.

TABLE 33-3   

GROUP LEADER COMMUNICATION TECHNIQUES

TECHNIQUE	EXAMPLE
Giving Information: Provides resources and information that support treatment goals	“Antidepressants may take as long as 4 weeks or more to show full therapeutic effects.”
Clarification: Asks the group member to expand and clarify what he or she means	“What do you mean when you say ‘I can’t go back to work?’”
Confrontation: Encourages the group member to explore inconsistencies in his or her communication or behavior	“Jane, you’re saying ‘nothing’s wrong,’ but you’re crying.”
Reflection: Encourages the group member to explore and expand on feelings (rather than thoughts or events)	“I notice you’re clenching your fists. What are you feeling right now?”“It sounds like that really upset you.”
Summarization: Closes a discussion or group session by pointing out key issues and insights	“We’ve talked about different types of cognitive distortions, and everyone identified at least one irrational thought that has influenced his or her behavior in a negative way. In the next session, we’ll explore some strategies for correcting negative thinking.”
Support: Gives positive feedback and acknowledgement	“It took a lot of courage to explore those painful feelings. You’re really working hard on resolving this problem.”

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