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11 Therapeutic Factors

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Instillation of hope Universality Imparting information Altruism The corrective recapitulation of the primary family group Development of socializing techniques Imitative behavior Interpersonal learning Group cohesiveness Catharsis Existential factors

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Installation of hope

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Group members gain inspiration through contact with individuals who have been in their place and made it through (ex:testimonials)

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Universality

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Nothing is truly outside the experience of other people

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Imparting information

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Completed through both didactic instruction and direct advice

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Altruism

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Group therapy allows individuals to be of benefit to other people

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The corrective recapitulation of the primary family group

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Group members can work through early familial conflicts correctively/clients reenact early family scripts in the group and, in successful group therapy, experiement with new behavior and break free from the rigid family roles into which they had long been locked

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Development of socializing techniques

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Members can develop more sophisticated social skills

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Imitative Behavior

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The process of members discovering who they are by imitating the counselor and other group members

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Interpersonal learning

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Includes three concepts: 1. the importance of interpersonal relationships 2. the corrective emotional experience 3. the group as a social microcosm

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Group cohesiveness

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Is the group therapy analogue to relationship in individual therapy/ the result of all the forces acting on all members such that they remain in the group or simply the attractiveness of a group for its members

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Catharsis

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is necessary but in itself not sufficient; need catharsis plus some form of cognitive learning (the ability to reflect on one's emotional experience is an essential component of the change process) Valued later in group development

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The importance of interpersonal relationships (interpersonal learning)

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W/out deep, positive, reciprocal interpersonal bonds, neither individual nor species survival would have been possible *NO ONE TRANSCENDS THE NEED FOR HUMAN CONTACT*

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Conditions for corrective emotional experience (interpersonal learning)

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1. the members must experience the group as sufficiently safe and supportive 2. there must be sufficient engagement and honest feedback to permit effective reality testing

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Types of critical incidents for corrective emotional experiences (interpersonal learning)

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1. Expression of negative affect- the client has always dreaded the expression of anger. Yet not catastrophe ensued. Ex: Sudden expression of strong dislike or anger toward another member 2. Expression of strong positive affect (unusual)- the feared catastrophe did not occur- derision, rejection, engulfment, the destruction of others. Ex: Ex: schizoid client runs after a member who had bolted from the room; schizoid client learned that he could care for and help someone else 3. A strong expression of emotion, which is interpersonally directed and constitutes a risk taken by the client. Needs a group that is supportive. Ex: self-disclosure that plunged them to explore the group in a deeper way

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The group as a social microcosm (interpersonal learning)

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Will occur when a freely interactive group, with few structural restrictions, is established -the more spontaneous interaction there is, the more rapid and authentic will be the development of the social microcosm

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Empathic capacity (interpersonal learning)

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Is a key component of emotional intelligence and facilitates transfer of learning from the therapy group to the client's larger world

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What is a critical element in a successful group? (interpersonal learning)

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Empathy

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Consensual validation (interpersonal leanring)

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The confirmation of reality by comparison of one's own perceptions and concerns with those of others, including the recognition and modification of distortions.

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What is the best interpersonal information about the client's impact on others? (interpersonal learning)

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The therapist's own reactions

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What is the most important relationship for clients to work through? (interpersonal learning)

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Transference

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What is insight? (interpersonal learning)

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When one discovers something important about oneself

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4 Levels of Insight (interpersonal learning)

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1. Learn how they are seen by other people. 2. May gain some understanding into their more complex interactional patterns of behavior (Ex: exploits others, competes relentlessly, pleads for love) 3. Motivational insight- clients learn why they do what they do to and with other people 4. Genetic insight- attempts to help clients understand how they got to be the way they are

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What is essential for the group to encompass the more challenging work that comes later?

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Early cohesion and engagement

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What is the precondition for other therapeutic factors to functional optimally?

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Group cohesion

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What is the positive, self-reinforcing loop of therapy groups? (group cohesion)

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Trust, self-disclosure, empathy, acceptance and trust

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What does belonging to the group do for individuals? (Group cohesion)

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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

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According to research, what types of clients have better therapy outcomes? (Group cohesion)

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Those who early in the course of therapy were most attracted to the group (group cohesion) and who were rated most popular by the other group members

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Highly cohesive groups have greater levels of what in the group?

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Self-disclosure

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What are the results of group cohesiveness?

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1. Better group attendance 2. Greater participation of members 3. Greater influenceability of members

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What factors seem to be responsible for the attainment of popularity in therapy groups? (Group cohesion)

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1. Previous self-disclosure 2. Interpersonal compatibility (individuals who have interpersonal needs that happen to blend well with those of the other group members) 3. Other sociometric measures. Typically, young, well-educated, intelligent and introspective. Those who filled the leadership vacuum that occurs early in the group when the therapist declines to assume the traditional leader role.

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Who has a higher likelihood of changing? (Group cohesion)

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Members who are popular and influential

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Why do people dropout? (Group cohesion)

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Had a little sense of belongings and left b/c they felt rejected, attacked or unconnected

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What is a necessary condition for effective group therapy? (group cohesion)

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Stability of membership

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What are norms? (group cohesion)

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Unwritten rules of behavior accepted by group members/Encourage open expression of disagreement or conflict alongside support

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What does conflict enhance? (group cohesion)

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Self-disclosure- as each opponent tends to reveal more and more to clarify his or her position

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What is the result of a group that is able to express negative feelings toward the therapist? (group cohesion)

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Members are strengthened by the experience- it teaches direct communication and provides an important learning experience

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What is group think? (Group cohesion)

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the deterioration of mental efficiency, reality testing and moral judgment that results from group pressure

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Members of a cohesive group will:

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1. try harder to influence other group members 2. be more open to influence by the other members 3. be more willing to listen to others and more accepting of others 4. experience greater security and relief from tension in the group 5. participate more readily in meetings 6. self-disclose more 7. protect the group norms and exert more pressure on individuals deviating from the norms 8. be less susceptible to disruption as a group when a member terminates membership 9. Experience greater ownership of the group therapy enter

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The importance of various therapeutic factors depends on what?

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They type of group therapy practiced

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The differential value of the therapeutic factors is vastly influenced by what 3 things?

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1. the type of group 2. the stage of therapy 3. the intellectual level of the client

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The ranking of the twelve therapeutic factors from research study (level of importance to participants)

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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. identification

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What are the three main categories of group therapeutic factors?

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1. early factors of belonging and demoralization common to all therapy groups 2. factors of guidance and instruction 3. specific skill development factors

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What is self-understanding?

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discovering and accepting previously unknown or unacceptable parts of myself- THE SINGLE MOST VALUED ITEM OF ALL

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How does self-understanding promote change?

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By encouraging individuals to recognize, integrate and give free expression to previously obscured parts of themselves

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What is the existential approach?

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The human'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 groundlessness the abyss 3. desire contact, protection, to be part of a larger whole, yet experience the unbridgeable gap between self and others 4. we are meaning-seeking creatures thrown into a world that has no intrinsic meaning

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Forgetfulness of being

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We live in the world of things, in everyday diversions

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Mindfulness of being

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we marvel not at the way things are, but that they are

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3 main tasks of the therapist

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1. creation and maintenance of the group 2. building a group culture 3. activation and illumination of the here and now

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The therapist must recognize and deter any forces that threaten group cohesiveness. What are these foreces?

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1. continued tardiness 2. absences 3. subgrouping 4. disruptive extragroup socialization 5. scapegoating

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If the group members who, in their interaction, set into motion the many therapeutic factors, what is the task of the group therapist?

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To create a group culture maximally conducive to effective group interaction

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How are group norms constructed?

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By expectations of the members and from the explicit and implicit directions of the leader (behavior of the therapist) more influential members

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What are the two basic roles of the therapist in group therapy?

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Technical expert and model-setting participant

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Technical expert

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To slip into the traditional garb of expert and employ a variety of techniques to move the group in a direction they consider desireable

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Model setting participant

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Leader sets a model of interpersonal honesty and spontaneity

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Self-monitoring group

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It is important that the group begin to assume responsibility for its own functioning. Ask the group "how has the group gone today? Are you satisfied with it?"

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Self-disclousre in group therapy is...

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absolutely essential- must be discussed in pre-group interview

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What is the optimal procedural format in group therapy?

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Unstructured, spontaneous and freely interacting (such a format never evolves naturally: much active culture shaping is required on the part of the therapist)

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In the group, who serves as agents of help?

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The other members of the group

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What are the two symbiotic tiers of the here-the-now?

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1st tier: the members live in the here-and-the-now; they develop strong feelings toward the other group members, the therapist and the group 2nd tier: the illumination of the 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

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Definition of process for psychotherapy

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It's the nature of the relationship between interacting individuals/members and therapists

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What must a therapist look for in the process?

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Sequence of statements made by several members

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How do you decide which process observations are correct?

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BASED ON THE IMMEDIATE NEEDS OF THE GROUPThe process begins with therapist reflection on the host of factors that may underlie an interaction. Observations are not mutually exclusive.

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Why can't you have a here and now experience in normal society?

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1. socialization anxiety 2. social norms (don't want to feel free to comment on the behaviors of others) 3. fear of retaliation 4. power maintenance (playing the game to move up)

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The first stage of the here-and-now

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activating phase- the therapist's task is to move the group into the here and now

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The second stage of the here-and-now

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Process illumination- reflecting back. The therapist is observer participant because he can reflect on the cyclical patterns of the behavior and to connect the events that have a occurred over the course of groups

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How do the past events of the therapy group play into the here and now?

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It is an integral part of the data on which process commentary is based

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What is the first step for the therapist to engage in the here-and-now?

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You think in the here and now

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How must the therapist teach the members to activate the here and now?

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With explicit instruction, by modeling, by reinforcing effective feedback and by teaching the clients to avoid global questions and observations

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How does resistance present itself in early meetings?

answer

It can be deeply ingrained and they want to hold on to that position. ex: quality, you either hate everybody in group or feel equally warm to everyone

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Techniques of process illumination

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1. observe the layout/dynamic 2. look at what is being said or done 3. look at behaviors when certain members are absent 4. look for parataxic distortions/displacement/metacommunication 5. look at group tensions: dominance and fear 6. look at primary task and secondary gratification 7. utilize therapist feelings

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What is the most powerful covert sources of group tension?

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The struggle for dominance (fluctuates in intensity throughout the group)

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Primary task

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to achieve goals, relief of suffering, better relationships with others or living more productively and fully

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Secondary gratification

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Ex: 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

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Basic premises of change

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1. only I can change the world I create 2. there is no danger in change 3. to attain what I really want, I must change 4. I can change; I am potent

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Why is your disclosure about the client's impact on you a particularly effective intervention?

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It deepens understanding for the mutual impact between therapist and group member

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Why might a therapist self-disclose?

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To facilitate transference resolution, to model therapeutic norms, to assist the interpersonal learning of the members who want to work on their relationship with the group leader, or to support or accept members

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What should a therapist do when they receive feedback?

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1. take it seriously listen to it and respond to it respectfully 2. obtain a consensual validation 3. check your internal experience-does it fit?

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Yalom's points about transparency

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1. always done with a purpose-the mechanism of therapy 2. always in the here and now 3. careful about personal life...again only therapeutic process and purpose

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Can pre therapy encounter predict group behavior?

answer

Yes

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Which intake interview is the least accurate?

answer

The traditional intake interview

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What is the most promising clinical method for determining if a client is a good fit for a group?

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To observe them in an intake and role play or if they are waitlisted how they react interpersonally

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What effects the character and process of the group the most?

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The composition

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Does heterogeneous or homogeneous matter in the composition of the group?

answer

No, neither have shown to be preferred through research. What really matters of cohesiveness and integrity.

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Who should not be included in group compostiion?

answer

People who may leave prematurely r are incompatible with the group culture. Group cohesion is most important and should not be confused with ease and comfort.

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What are the characteristics of the advanced group?

answer

The group has an increased ability for reflection, authenticity, honesty, self-disclosure, and the ability to give and receive feedback. It has achieved a degree of maturity and stabilization where the members are engaged and working through their issues and are more invested in the group and the therapeutic factors are working with effectiveness and strength

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What does Yalom mean by saying the therapist gets to practice the art of psychotherapy?

answer

The therapist can synthesize his clinical experience, his reading, his hours of supervision, and intuition and put all of that to work in the basic role of the therapist in individual and group the

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What are the issues that cause problems in the advanced group?

answer

Subgrouping conflicts early termination self-disclosure that hurts the group

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Why does Yalom call subgrouping the Achilles heel of group therapy?

answer

Subgrouping impedes the process and only gratifies the individual's need. Even though they are supposed to be forming meaningful relationships and transferring this knowledge outside of the group. They instead try to fill that immediate need in the group, which impedes the process of the whole group

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What is extragrouping vs. subgrouping?

answer

extragrouping is the precursor to subgrouping. They socialize, get coffee and if they come back and share it with the group as a whole, it can enhance the group. If they don't share with the group, it becomes subgrouping, which is detrimental to the group process.

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the effects of subgrouping

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It disrupts the course of therapy for the group, it can cause premature termination (b/c others feel excluded and stops the group from reflecting and being honest)

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How can subgrouping enhance the group process?

answer

It can only be helpful if the goals of the subgroup are in alignment with the goals and norms of the process group. This issue of subgrouping is silence and not bringing it back into the group.

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What is the therapist's role when subgrouping occurs?

answer

To encourage open discussion and analysis of all group activity. the therapist would be wise to set this as a precondition to therapy and talk about it in initial sessions

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How does conflict play out?

answer

compete for therapist's attention (sibling rivalry), clients with poor self esteem respond with anger, retaliation, rejection, etc. , they can have unrealistic goals of therapist and therapy as a whole, new members coming in, can create hostility because they alter new roles

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What can be the result of conflict?

answer

Scapegoating (dumping anger on one person) and Mascoting (disregard a member)

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What is the therapist's role in conflict concerning scapegoating or mascoting?

answer

The therapist views this as a jointly entered into by the group. The other members made the individual a scapegoat, but the individual let them.

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Why does Yalom refer to termination as "a mutually planned ending to therapy?"

answer

Termination is a positive integral part of therapeutic work and has specific aspects of it including mourning, reflection, and celebration. Termination needs to be clearly stated and people need to confront boundaries and limits of the ending of therapy.

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What are important things for the therapist to consider for termination?

answer

The therapist has to realize that termination is an important force in the process of change and that it is highly individualized

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What is important to consider if the therapist terminates?

answer

Therapist must find someone to replace him/her immediately and new therapist should meet with each group member individually.

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When groups terminate

answer

Some groups terminate, because they are brief. And open groups terminate when therapist retires or when everybody has attained their goals. Therapists remind members regularly that termination is coming. While also keeping them focused on their goals.

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What is the cruelty of psychotherapy?

answer

The therapist will lose every client and as therapist's we must experience that loss and discomfort. We become a participant by disclosing our own feelings and this eases the goodbyes of the group.

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Three obstacles to group therapy

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1. Encounter group movement 2. Therapists like the one on one with the client 3. Therapist avoid anxiety of facilitating the group

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Four major components that are essential to a comprehensive training program

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1. Observation of experienced group therapists at work 2. Close clinical supervision of students maiden groups 3. A personal group experience 4. Personal psychotherapeutic work

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Criteria for exclusion

answer

individuals who are brain-damaged, paranoid, hypochondriacal, addicted to drugs or alcohol, acutely psychotic, or sociopathic. Individuals who are in an acute situational crisis. Deeply depressed suicidal clients. 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.

question

Reasons for premature termination

answer

External factors, group deviancy, problems with intimacy, fear of emotional contagion, inability to share the therapist, complications of concurrent individual and group therapy, early provocateurs, inadequate orientation to therapy, complications arising from sub-grouping

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Criteria for inclusion

answer

Motivation, problems in the interpersonal domain, individuals who highly value and desire personal change

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Open group

answer

Maintains consistent size by replacing group members as they leave the group. May or may not have a predetermined length of time for meeting.

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Closed group

answer

Accepts no new members after the first 2-3 sessions. Meets for a predetermined length of time.

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Duration, frequency and size

answer

80-90 minutes are most successful, weekly meetings are most common - Yalom prefers bi-weekly if possible. Ideal size is 7-8 members, 5-10 is acceptable

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Common group problems

answer

Perceived goal incompatibility. High turnover Does not offer immediate comfort Subgrouping and extragroup socializing

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Preparation group summary

answer

Explain therapy process Describe what types of behaviors are expected Establish contract regarding attendance Raise expectations about the effects of the group To predict and ameliorate problems and discomforts in early meetings Comprehensive preparation enables the client to make an informed decision about whether to enter a therapy group

question

Formative states of development

answer

Forming Storming Norming Performing Adjourning

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The initial stage

answer

Orientation, hesitant participation, search for meaning, dependency

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The second stage

answer

Conflict, dominance, rebellion

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The third stage

answer

Development of cohesiveness

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Membership problems

answer

1. Turnover 2. Attendance and punctuality 3. Dropouts 4. Removing a client from a group 5. Addition of new members

question

Monopolist

answer

A bête noire (the person or thing that one doesn't like). A person who seems compelled to chatter on incessantly. Behavior must be checked and often!

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Silent Client

answer

is a problem client and rarely benefits from the group. Less disruptive but equally as challenging. Group members who slowly self-disclose, rarely catch up to the group. Understand the dynamics of the silence. Include the client by commenting on the non-verbal behavior.

question

Boring Client

answer

Some clients are alexithymic (a personality characterist in which the individual is unable to identify and describe their emotions). Generally, the client is massively inhibited, lacks spontaneity, never takes risks, speaks to appease other group members, and the social style varies by individual

question

Help Rejecting Complainer

answer

Shows specific pattern: implicitly or explicitly request help from the group by presenting problems or complaints, only to reject any help offered. May also express through somatic complaints. Assisting them in seeing their interpersonal impact on the group can be key in self-examination and awareness.

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Psychotic or Bipolar Client

answer

Group reaction varies based on timing of the group. New groups often struggle, more mature groups display empathy. If kick out of the group, always leave an option for client to see you individually.

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Characterologically Difficult Client

answer

Often clients has experienced traumatic abuse early in life. Referred for group because 1. transference has grown to heavy for dyadic therapy. 2. the client has become defensively isolated 3. therapy has gone well, but a plateau has been reached.

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Schizoid Client

answer

Nearly every meeting they have evidence that what they experience emotionally is completely different than that of the other members. They are in need of new skills and new internalized experiences in the world of relationships. Encourage work in the here and now, differentiate amongst group members, observe their own body. Schizoid clients are high risk, but high reward.

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Borderline Client

answer

Instability of mood, thought, and interpersonal involvement. Many suggest group therapy because treatment on an individual basis has proved extremely difficult. The intensity and intimacy of one on one sessions is often too heavy a task for the BC. Group therapy can help ease feelings of Separation anxiety and fear of abandonment.

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Narcissistic Client

answer

Presents with grandiosities. Feel alive when "onstage". Often object when someone points out similarities between themselves and the NC. May respond negatively to key therapeutic factors such as universality and cohesion. Accelerates the group.

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Specialized therapy group steps

answer

1. Assessment of the clinical setting. 2. Formulation of goals 3. Modification of traditional technique

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Excessive reliance on exercise techniques renders a group less effective

answer

The group that prematurely bonds due to use of exercises may circumvent many group developmental task and become reliant on the exercises themselves

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Structured exercise denotes

answer

an activity in which a group follows some specific set of directions

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Audiovisual Technology

answer

The use of audiovisual techniques in teaching and research have proven to be very effective. Self-observation is powerful; nothing is as convincing as information one discovers for oneself. The person who experiences the most discomfort in being filmed is perhaps the therapist in fear of being exposed or shamed. If the tape is to be viewed by anyone other than the client or group members, therapist must obtain written permission and be explicit in the purpose

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A summary is

answer

an editorialized narrative that describes the flow of the session, each member's contribution, therapist's contribution (not only what was said but what he/she wished was said, and any hunches or questions that occur to therapist after conclusion of session

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The investigation of certain dreams accelerates group therapy and the most valuable are group dreams or those that involve the group as a reflection of the dreamer's feelings

answer

Ask the question, "Why this dream now?" Dreams often reveal unexpressed group concerns or shed light on group blockages and impasses

question

General Concerns from participants in a group therapy setting for leaderless meetings

answer

The group would stray from the primary task. The group would lose control of its emotions. The group would be unable to integrate its experiences and to make constructive use of them

question

Co-therapists

answer

Clinicians recognize the advantages and potential hazards of co-therapy. Therapist must set aside time to collaborate, talk, and debrief. Co therapist matching is crucial. Whether co- therapists should openly express disagreement during group is very controversial. Co- therapists choice is very important and a therapist should not agree to the partnership if they foresee potential pitfalls

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Crosstalk is different than member- to- member interaction

answer

Crosstalk can be any direct inquiry, suggestion, advice, feedback or criticism. AA prohibits "crosstalk" and some clients may be unfamiliar with the concept when engaging in mainstream group therapy

question

The common misconceptions held by group therapists and by members of AA:

answer

i. Twelve- step groups are opposed to psychotherapy or medication. ii. Twelve- step groups encourage the abdication of personal responsibility. iii. Twelve step groups discourage the expression of strong affects. iv. Mainstream group therapy neglects spirituality. v. Mainstream group therapy is powerful enough to be effective without twelve-step groups. vi. Mainstream group therapy views the AA relationships and the relationship between sponsor and sponsee as regressive.

question

steps to take when issues of boundaries with confidentiality arise

answer

1. Repeated urging of the client and investigation of resistance 2. Sending knowing glances at client urging them to share in group 3. Ask client permission to introduce the material to the group

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Two conditions must be met for either conjoint or combined to be successful

answer

1. collaboration and 2. complementary

question

Combined therapy is

answer

when a client is treated by the same therapist in both individual and group therapy.

question

Conjoint therapy refers to

answer

a treatment format in which the client is seen by one therapist for individual therapy and a different one for group therapy.

question

Therapist Tasks:

answer

1. Activating phase: move the group into the here and now 2. Process illumination: history, repetitive cycles, observer and historian

question

How Do We Guide This Process of Will (to change):

answer

A. Only I can change the world I created B. There is no danger in change C. To attain what I want I must change D. I can change. I am potent.

question

Encounter group

answer

is a rough, inexact term that encompasses a great variety of forms and has many aliases: human relations group, T-groups, sensitivity groups, personal growth groups, marathon groups, human potential growth groups, sensory awareness groups, basic encounter groups and experiential groups.

question

How did encounter groups influence contemporary group therapy?

answer

Feedback, observant participation, unfreezing and cognitive aids

question

Four important leadership functions:

answer

1. Emotional activation: challenging, confronting, modeling by personal risk-tasking and high self disclosure. 2. Caring: offering support, affection, praise, protection, warmth, acceptance, genuineness, concern 3. Meaning attribution: explaining, clarifying, interpreting, providing a cognitive framework for change, translating feelings and experiences to ideas. 4. Executive function: setting limits, rules, norms, goals, managing time, pacing, stopping, interceding, suggesting procedures

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