CHAPTER 2

CLINICAL AND RESEARCH EVIDENCE


We have explored a number of different theories which contribute to our understanding of the group phenomena. I have, in the main, let the cited theorists speak for themselves, describing their own views of group development, each derived largely from their own experience, education, and professional attitudes. Freud, Adler, Jung, and Frank contribute the perspective of psychiatry; Tillich and Oden, theology and experience as pastoral counselors; Fromm and Mead, social philosophy and psychology; Cooley, sociology; and Konner, medical anthropology.

            In this chapter I will not focus on the group as a whole but on specific activities which may or may not take place within the group. I have alluded to the fact that group participants may have beneficial experiences where they are supported in a social, interpersonal sense or, to the contrary, may actually find the experience harmful. This does seem paradoxical: that a person would continue to participate in a group to his or her detriment. Recent history shows us, all too often, the development of violent cults, sometimes destructive to society, sometimes self destructive, often both. The drawing power of group membership may be similar in groups with positive membership effects as well as those with detrimental effects. Motivation and expectations may differ in many ways for individuals joining a group. We will find that the quality of interaction among members is very important to this topic. 1
            While I have previously referred to the Transformation in the Group, at this point I will use the word “change” in a more precise manner. Transformation is a general term in this context. It refers to both Group development, including shifts of interest and themes within the Group, as well as individual members’ personal development resulting from reciprocal influences between members and the Group. Transformation is difficult to describe exactly and is referred to and expanded on throughout this study. Like the word “culture”, any activity of, or related to a group, may be a component of transformation.

            Change, on the other hand, pertains to a specific event or a specific person. It is a measurable happening. As an example, consider the chemical equation:

                

2H2 + 02  →  2H2 O + Heat


Given a measureable amount of the gases hydrogen and oxygen: mix them, then ignite them. After the explosion there will be measureable amount of water and energy generated. Some of the water will be liquid, some gas, but always the same amount in proportion to the original hydrogen and oxygen. The amount of energy liberated (in the perceptual form of heat, light, and expansion in space) is also proportional to the amount of hydrogen and oxygen that reacts.

           When describing change, I am attempting this level of definition. Now I will backtrack somewhat. Methods to measure the types of change that we are interested in this accurately with human beings require very controlled testing procedures or very narrow parameters. An example of this precise description of change may be illustrated by comparing an EEG tracing before then after administration of a drug, strobelight, hypnosis, meditation, or even during participation in group discussion. [Ornstein and Galin: “The Physiology of Consciousness” (167) and Galin: “Two Modes of Consciousness and the Two Halves of the Brain” (80) are two summaries of research in just this area that have recently come to my attention. These are examples of comparisons of lateral brain hemisphere EEG activity during different tasks. Even more recently, the work of Daniel Amen (5) diagnoses and treats specific mental-emotional disorders using Single Proton Emission Computed Tomography: “SPECT” to identify specific neural-physiological-structural issues causing difficulties within the brain.] Testing measures a definite change but does not tell us very much about actual processes that are taking place in interaction between people. In studying change that takes place among members of a group, the experience is similar to that of studying the fresco of Leonardo’s Last Supper with a magnifying glass. You may learn about the components of paint and how it is applied but miss the total effect of the completed composition.

            The lens through which I wish to investigate change in this study is that of research focusing on outcome for participants in group psychotherapy and participants in encounter groups. Two reasons have contributed to this choice. First, psychotherapy is a method of change. That is its purpose, and that is what the most relevant research pertaining to it focuses on. Second, the change is meant to benefit the individual. This may be an improved emotional or interpersonal life. It may even encompass an improvement of health. This is a return to an issue that is of continual importance when we study groups or become members of a group. The process of becoming a group member should involve a ‘healthful’ change, whether a conscious goal, as in group therapy, or a beneficial side effect, as in the numerous groups, in our communities, that we all join for various other reasons. The goals of psychotherapy include members changing from a state of lesser health to improved health. Participants join encounter groups for various reasons. Some may have self improvement as a goal, but for others curiosity or entertainment may be motivation. In the research cited in this chapter, class credit or education in a field of psychology is also a reason for participation. Studying change in these instances widens the field of research. We may be able to extrapolate our research to form certain generalizations about what must take place in a Group for it to be a healthful experience for all members.         


The study of individual change, while more specific than transformation, is a tremendously complex study in itself. Take an example of a 27-year old man, Gus, who has come to group therapy because he feels continuously criticized by family members and fellow workers. He couldn’t say why, but he was becoming more and more depressed. (These examples are based on case histories from reports during Group discussion and occasional individual counseling sessions; names and identifying features are changed.) After the fourteenth meeting a change has taken place. Gus, who was initially nervous and unsure about group therapy—expecting more criticism, now from a bunch of strangers—finds that he actually looks forward to the next meeting. He feels that he can follow conversation in the Group that was initially confusing and often too fast for him to track on. He has some things he wants to tell a couple of the other members about their issues. Stimulation of interest and even entertainment can be regarded as a component of this change. Interest in other members is especially encouraging.

            After the twentieth session our subject goes home a bit shaken. He has been told by another member that he always projects a cold, aloof attitude toward others, acting as though he knew everything. This other Group member did not mince words and seemed quite angry. Another member agreed with her. What bothers Gus is that this is how he feels that people at his job treat him. He experienced several emotions: hurt then anger, but after several days he made a resolution to change. He consciously tried to pay attention to what one of his fellow employees at his work was saying about himself. Gus realized that this is something that he does not do very well; he usually focuses on himself. (This procedure may have been inspired by a conversation, a few weeks earlier, between two other members about methods of introducing themselves to other people. Gus listened but did not participate.) With some difficulty he asked general, friendly questions about his co-worker’s family. He reported to the Group that he felt somewhat uncomfortable, but his co-worker volunteered more information and seemed to enjoy talking about himself, his wife, and children.

            During the next meeting, while describing this conversation, another member responded to Gus that he never seemed to be concerned about anyone except himself. Several other members had comments to the effect that while this seemed true at first, Gus’s new attempt to listen to others was real improvement. During subsequent Group sessions Gus continued to practice new ways of interacting in role-play and became more effective when talking to people in the Group. He even began to practice initiating and stimulating conversation. Group members began to joke playfully with Gus about his ‘project’ of becoming a conversationalist. This definitely had become a method that he used to develop more socially effective communication. With some hesitation Gus began to describe discomfort he feels in public and a tendency to withdraw. This, then, became a focus of therapeutic work.

           When we look at Gus’s behavior, we see an observable change. Gus’s Group peers, by becoming interested and involved, helping Gus with his ‘project’, also started practicing their own interactions in more conscious manners within the Group but also with people they communicate with in their day-to-day lives. The tone of the Group also changed. While originally hesitant in their interactions toward Gus, they became more supportive and even playful toward him and each other at times.

            Carla, a college freshman, could not study when she started participating in the Group at the campus counseling center. She was referred to the counseling center as she was having a great deal of difficulty concentrating on her schoolwork. When she sat down with a book to study, she became preoccupied: telling-off and/or showing-up various people in her imagination. There were some stormy sessions in which she suddenly seemed to blow up at other members. As a result she had several individual sessions with the Group leader. She took a time out from the Group and worked individually with a different counselor but returned to the Group after two months. As she vented and learned relaxation exercises, as part of structured Group practices, the focus of her rage changed. This became more personal. The people she imagined telling off were specific classmates from high school and, later, family members. Although that quarter did not go well with her grades, by the next quarter she was able to complete assignments and concentrate on school work at least an hour a night. She expressed mild surprise to other members in her Group that they did not criticize her for her poor grades but still accepted her as a Group member. Several of them even had some similar issues with studies as well as pressures from family and difficulty meeting these expectations. The Group leader, with the authority of the counseling center, helped her arrange time and tutoring help with instructors, as well as ways to improve some of her grades for the classes that she was having trouble with. In later Group sessions she commented that she had never experienced this type of support from previous teachers or family before.

            Allen, at twenty, has more Group experience than most people. Arrested at fifteen in a raving condition at a rock concert, then brought into the county hospital and subsequently transferred to a locked adolescent psychiatric ward, he was selling and apparently using what he called “Bad THC” which was probably a mixture of speed and PCP. He spent several weeks in an adolescent psychiatric ward then was assigned to a highly supervised group home after his thought processes became more organized. His mother showed little interest in his disposition; actually, she seemed afraid of him and certainly unable to control him in any way. His father could not be located.

           Later in the course of his treatment his mother became more supportive and concerned with him. She had been having difficulties with Allen while caring for his younger siblings and supporting the family. She was overwhelmed. Consequently she also received a referral with some counseling support. Often a crisis with the most obviously disturbed member of a family opens up the family for help to other members. This theme has been touched on in the previous chapter and will be reinterated in the description of the Crisis Intervention Workshop.

           After several years of group home experience, including a run-away episode, followed by a short stint in juvenile hall and return, Allen has now lived in a half-way house of his own choosing for the past year. (This case dates back to the 1970s when funding was still available for this type of treatment. Rev. ed.) He has a job at a market and pays a portion of room and board, has cleared his legal issues, takes two classes at a community college, and is seeing a girl regularly, although he states that he also sees others. Allen attends a bi-weekly Group of residents of the halfway house. At the group home where he was initially assigned he was in a Group that met five times a week, as well as sponteneous emergency meetings when crises with the residents arose, and daily morning and evening check-ins. This was throughout his two years of residency. He states: “Those meetings were really bad. Most of the kids there don’t give a shit. I’m glad that’s over. But when I went there I was really screwed up. I was loaded all the time. I thought that I was God and grown-ups were the devil, trying to always fuck with your mind, you know. I never want to get there again but it wouldn’t be that hard. The group here’s a pain the ass sometimes, but if I get down, they won’t let me go out and get fucked up and that’s good!”


With these case summaries only surface details of how change comes about have been touched on. There are several levels of complexity of change which may be summarized:

•  Attitude :  A Group member often begins participating with uncertainty and a question presented as a problem. As he or she becomes more involved in the Group conversation, interest and curiousity develops which fuels motivation. Often the new member experiences a sense of challenge but also relief from being able to discuss personal issues in depth. Members derive pleasure or entertainment from participation which enhances Group communication and the therapeutic process. Group discussion stimulates members interest in the procedures and methods of change—often new information for them. This is actually an educational function, mostly cognitive, a transition between an enhanced awareness of attitude and a positive shift of values. Even if a Group is called ‘nondirective’, the participation in this style of interaction encourages a new experience that affect the ways that members usually communicate with others.

•  Values: Members develop new views of themselves and the world. Plans to change and even new ideas of what positive change can be accomplished are discussed and shared by Group participants. A clearer, more critical sense of oneself, one’s behavior and issues related to personal problems are developed. Members often make resolutions to change and even make plans. Although this does not mean that these resolutions will be completely successfully fulfilled, they represent a shift in cognitive values and the beginning of a process that will lead to a more profound change in behavior and life style. Therapy starts with discussion about what has blocked or interfered with planned change and what can be done about this situation.

•  Emotion: If Group therapy is successful, members will not be so encumbered by feelings that interfere with their functioning or intent. Growth of positive feelings energize new attitudes and behavior.

•  Personality:  On the deepest level, a Group member may actually be a different person after being a member of a Group. Personality change is an integrative function of the three previously discussed levels. This may take years of work, often involving times of great discomfort and is most successful with a person such as adolescent Allen, whose personality is still forming and is at an age of ‘normal’ developmental crisis. In this case Group participation mediates and helps the person form into a healthy personality rather than a psychopath. At the point when Allen was arrested then hospitalized, he could have developed in either direction. Institutionalization of criminal behavior and/or mental illness was the most likely without intervention. Carla, also adolescent, presents with both situational and maturational issues, distinctions discussed in the final chapter about crisis intervention. While she is less likely to develop criminal behavior, the preoccupation that she experiences and receives counseling for, could, without intervention, continue to be debilitating in her later life.

We can see that positive change on one level does not necessarily indicate positive change on another level. If we use a very simplified framework to indicate change, ignoring variation or gradation, we can describe change in a positive or negative direction on each of these levels or indicate that a person remains unchanged. With the four indices that I have listed: Attitude, Values, Emotion, Personality, we now have 81 (three on each level, four levels = 34=81) possible combinations of change. These four levels of change have been emphasized for study purposes. There are many more effects that develop in Groups and some of these will emerge in the following chapters.

            Thus, at the fourteenth week Gus has changed toward a more positive attitude toward the Group. His values, emotions, and personality have remained unchanged. At the twentieth week we now see the beginning of a positive shift in values, but we have no indication of his attitude toward the Group, or possibly there is a shift toward a negative. Occasionally confrontation will result in this type of negative shift. As his Group experience continued Gus actually became aware of uncomfortable feelings that he experiences, especially toward others. As he grew to trust other Group members, he explored some of these feelings: their strength and sources. With this awareness he continued to develop new ways of interaction. Attitude change was the beginning of this process. As his awareness developed, he worked toward a change of his emotions.

            When Carla was last surveyed, she had a less negative measure of emotion than initially. When she began the Group she seemed to act in a rather disinterested manner, but then suddenly she experienced a period of terror about attending Group as she later reported. She expressed fairly uncontrolled rage toward other Group members leading to the arranged time-out. At the time of this writing, she feels more comfortable during group and comments that the Group has helped her. Paradoxically, she resents having to attend a therapy Group, but now states that this resentment is not toward other members, whose company she likes, but toward people outside the Group, usually referring to her “friends” in high school from whom she experiences constant judgment. She reports that she is the same person with the same values but is less encumbered by the anger and terror that she felt a year ago.

            Allen, on the other hand, describes himself as an entirely different person: “Everything was like a bad dream. Now I live in reality. I was a snotty little kid, pissed off all the time. Now I’m strong, like a steel rail, and if I’m not, I can talk it out. I don’t have to take off.” He does not express particularly positive feelings about the Group but sees it as necessary for his survival. Actually for a twenty year old male with a very embattled adolescence this last statement is probably a glowing compliment of group process and the help he gets from other members, considering that he now is on the way to self sufficiency. We can see that his values are greatly expanded just by looking at his behavior and life-style. By his description as well as evidence from his case history, at fifteen his only interest was apparently drugs.      

            On the emotional level, Allen presently expresses more hope for the future, although, as indicated, he experiences depressed moods.  It is during these periods of “getting down” when he feels that the Group helps him the most by setting limits and occasionally even physically restraining him from leaving the half-way house to “go get loaded.”


While I have used the above examples to illustrate some of the complexities that come from studying just four levels of change, much of the research that I will review in this chapter comes from a massive study of encounter groups done at Stanford University by Leiberman, Yalom, and Miles. Seventeen groups were studied, each led by acknowledged group leaders, with different styles, theoretical practice, tradition, and training [Yalom’s 4th edition states 18 groups. Previous editions and L, Y, & M (136) state seventeen (253).]. While this study was done following the outcomes of encounter groups, it is very similar to methods recommended by Powdermaker and Frank [ Group Psychotherapy: Studies in Methodology of Research and Therapy (183)] for psychotherapy groups. Pre-tests, post-tests, follow-ups six months after termination, self reports, and reports by group members about other group members have been collected. The authors isolate not less than thirty-three levels on which change takes place!

        Yalom summarizes the study in his now classic group psychotherapy text:

These self-administered instruments attempted to measure any changes one might think encounter groups would effect: e. g., self-esteem, self-ideal discrepancy, interpersonal attitudes and behavior, life values, defense mechanisms, emotional expressivity, values, friendship pattern, major life decisions, etc.

        The assessment outcome was strikingly similar to that of a psychotherapy project but with one important difference: since the subjects were not patients but ostensibly healthy individuals seeking growth, no assessment of “target symptoms” or “chief complaints” was made.

        Leader style was studied by teams of trained raters, who observed all meetings and coded all behaviors of the leader, by tape recordings and written transcripts of the meetings in which all leader statements were recorded and analyzed and by questionnaires filled out by participants.

        Process data were collected by the observers and from questionnaires filled out by participants at the end of each meeting.

The Theory and Practice of Group Psychotherapy (253:474)

The focus of a part of the study was to determine what qualities the leader must possess in order for a group member to be helped by the experience. In recent years there has been a growing realization and body of evidence that some people who have been participants in encounter, sensitivity, T-groups and similar organizations in the larger community, have been hurt by their experience. Consequently, there was interest in determining what led to any casualties that may have occurred.


The following outcomes were found:


A. IMMEDIATELY AFTER THE GROUP

                      Casualties      Negative     Drop-Outs    Unchanged          Moderate                  High

                                           Changers                                                   Changers                   Learners

                      ________   ________    ________   _________             _______               _______

Participants          8%             8%             12%            38%                        20%                     14%

Controls             23%                                                   60%                        13%                       4%


B. RETEST AFTER SIX MONTHS    

                      Casualties       Negative    Drop-Outs    Unchanged             Moderate                 High

                                            Changers                                                     Changers                  Learners

                      ________      ________ ________     _________            _______                 _______

Participants         10%                 8%         17%                 33%                     23%                         9%

Controls              15%                                                        68%                     11%                         6%

There were 206 participants and 69 controls originally.  160 participants and 47 controls were located for the six month sample.


C. COMBINATION SCORES: Combining the Casualties, Negative Changers and Drop-Outs as a category of Group Failures, and the Moderate Changers and High-Learners as Group Success obtains the following percentages:   

      

                                                          Group Failure                     No Effect                Group Success

                                                         ___________                    ________             ____________

IMMEDIATE 

Participants                                             28%                                 38%                          34%

Controls                                                  23%                                  60%                          17%



SIX-MONTHS

Participants                                             35%                                  33%                         32%

Controls                                                  35%                                  68%                         17%

Encounter Groups: First Facts (136:475-476)


It would appear from these figures that the general effect of encounter group participation on the entire population, when compared to controls, was to move some participants immediately after the group experience, from unchanged positions toward either success or failure. At best we can say that there were more successes that maintained their positive change than failures, although immediately after the group there were increased failures compared to control. After six months the control and participant failure were equal. Yalom writes:


Put in a critical fashion, one might say (this) indicates that of all subjects who begin a thirty-hour encounter group led by an acknowledged expert, approximately two-thirds found it an unrewarding experience (either dropout, negative change, or unchanged).

Theory and Practice of Group Psychotherapy (253:475)

The following percentages are obtained if the Drop-Out numbers are removed. This procedure may be justified in light of this experience being presented as a class. Many of the original participants were only expecting class units or credit, not expecting the personal involvement that a small group presents; they dropped the group as they would drop an undesirable class.

Adjusting the above percentages to measure only those who completed the group experience, the following figures were obtained:

D.  PARTICIPANTS COMPLETING STUDY  

  .                          Casualties       Negative           Unchanged               Moderate               High               

                                                    Changers                                           Changers               Learners

                             ________       ________         ________             _______                 _______

IMMEDIATE              9%               10%                 44%                     22%                         16%

SIX-MONTHS          12%               10%                 39%                     28%                         11%



E.  PARTICIPANTS COMPLETING THE GROUP -- COMPILED DATA                           

                                              Group Failure                           No Effect                          Group Success

                                               ___________                        _________                        ____________

Immediate                                       19%                                     44%                                   38%   

Six-Months                                     22%                                     39%                                   39%

Encounter Groups: First Facts (136:475-476)

            

With this treatment of the data, the group success figures are definitely higher than the control figures (38%, 39%, from this table, compared with 17%, 17%, controls from Tables C).  The failures remain high, however (19%, 22%, compared to control 23%, 35%).  A rule of thumb, then, for a random sampling of encounter groups, is that while the experience seems to help some voluntary participants, there is a clear risk that others may be harmed.   The rate of success is higher than the rate of failures for some groups, but this is not always the case!

            It is also interesting and significant that, of the participants who completed the groups, 65% found them pleasant, 78% constructive, 61% a good learning experience and 50% a ‘turned-on’ experience.  An average of 4.7 participants viewed the experience as productive for every 1 who viewed it as negative. Six months later this ratio dropped to 2.3 to 1, but this still represents an overall successful experience for participants at the Attitude level of change (136:474). This finding seems to contradict Yalom’s statement above, that two-thirds of the participants found the groups unrewarding. He probably should have written that approximately two-thirds of the participants had an unsuccessful experience  according to objective measures.  On the other hand 4.7 times as many participants (2.3 at six months) experienced the groups as productive for every one that did not. This shows a large gulf between participant experience and objective findings.  These measures further demonstrate the impression that we have from other sources that many people are vulnerable to participation in social organizations that are not necessarily to their benefit.


So far we have been looking at the research on such a general level that a great deal of vital information has been hidden in the numbers. The statistics were culled from the study of seventeen different groups led by seventeen different leaders. Or possibly we should consider them led in seventeen different manners, as two groups were ‘led’ by a programmed tape. (Yalom’s 5th edition states 18 groups.) The success of the groups varied widely. There were groups with no casualties, no negative changers, and several moderate and high changers. On the other hand, there were groups with several casualties and negative changers and few or no improvers (136:476).

              Liebermann, Yalom, and Miles focus on the characteristics of the leaders. First they look at their training and orientation. There were leaders who represented the following schools or traditions:


•  National Training Laboratory – Basic Human Relations Group, T-Group, Sensitivity Group.

•  Gestalt Therapy.

•  Transactional Analysis.

•  Esalen Eclectic.

•  Personal Growth – National Training Lab, Western Style.

•  Synanon.

•  Psychodrama.

•  Marathon.

•  Psychoanalytically Oriented.

•  Encounter Tapes – two leaderless groups ‘led’ by Bell and Howell “Encountertapes.”

       Encounter Groups: First Facts (136:472-473)



Our researchers found that these labels give us only the vaguest sense of what actually took place in the groups and certainly could not be used to predict success.

          Yalom summarizes:

The behavior of the leaders when carefully charted by observers varied greatly and did not conform to our pre-group expectations. The ideological school to which the leader belonged told us little about the actual behavior of the leader. We found that the behavior of the leader of one school, for example transactional analysis, resembled the behavior of the other T. A. leader no more closely than that of any other seventeen leaders. In other words, the behavior of the leader is not predictable from his membership in a particular ideological school.  Yet the effectiveness of the group was, in large part, a function of the leader’s behavior.


Theory and Practice of Group Psychotherapy (253:476)

QUALITIES OF GROUP EXPERIENCE LEADING TO POSITIVE (HEALTHFUL) CHANGE


Four different leadership functions were identified by factor analysis:

         1. Emotional Stimulation (challenging, confronting activity; intrusive modeling by personal risk-taking and high self-disclosure).


         2. Caring (offering support, affection, praise, protection, warmth, acceptance, genuineness, concern).


         3. Meaning Attribution (explaining, clarifying, interpreting, providing cognitive framework for change; translating feelings and experience into ideas).


          4. Executive Function (setting limits, rules, norms, goals; managing time; pacing, stopping, interceding, suggesting procedures).


    Theory and Practice of Group Therapy (253:477).

Outcomes measuring success or failure were then factored for each group. These frequencies were compared to the “leadership functions” by which the groups were conducted.


It was found that Caring and Meaning Attribution relate directly to outcome. In other words, leaders who exhibit these behaviors in their styles of leading had the most positive outcomes in their groups. They also had few Negative Changers. This result was especially pronounced when both factors were present and the positive outcome increased as frequency of the factors increased (253 :235-239).

Emotional Stimulation and Executive Function are important to outcome also, but these factors must be maintained at an optimal level, which seems to be a medium intensity. Too much or too little lowers their effectiveness (253:235-239).

The most successful leader, then, was the one moderate in amount of emotional stimulation and an expression of executive function and high in caring and meaning attribution. Both caring and meaning attribution seemed critical, but neither, alone, was sufficient to insure success.

Theory and Practice of Group Psychotherapy (253:477)

…the less effective leaders would be those who are very low or very high in stimulation, low in caring, do very little meaning attribution, and display too little or too much executive behavior.

Encounter Groups: First Facts (136:240)

In light of this discussion of effectiveness of leaders, it is interesting to note that of the two tape led groups, # 16 had a slightly negative effect, while the other, #17, was the second most successful group of the seventeen.


Group #16 (Tape) members showed decreased adequacy in coping, decreased need for affection from others, and a decreased tendency to view others as lenient.



Group # 17 (Tape) stands in sharp contrast to the previous tape group.  Members of this group increased values focusing on the self, increased in the their sense of adequate or active coping strategies, viewed themselves as more lenient, and perceived the environment as offering increased opportunities for open peer communication.

Encounter Groups: First Facts (136:128)

While the unsuccessful group was characterized as: “Obedient, responsible, low conflict, cautious here-and-now programmed warmth and support” (136:87), the more successful tape group is described as follows:

Group #17 was considerably different from the other tape group. It was far less placid; the members more often expressed their dissatisfaction with the tape recorder. They would refer to the tape program as “George” in jocular ridiculing fashion. When the tape program suggested, for instance, that they do a certain exercise, someone would interrupt to say, “Oh, that’s a great idea, George.” In the last three meetings, the group played the tape all the way through at the beginning of the meeting, and decided whether of not there was any part of the taped instructions they wished to follow for the day. This was counter to basic instructions, which were to play the tape and follow its own instructions about when it should be turned off and on during the meeting.

Encounter Groups: First Facts (136:89)

We will return to comment on these Tape Led Groups at the end of this chapter.


In summarizing the characteristics of leadership for a successful group, Yalom states:

…we obtained surprising results which disconfirmed many of the current 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 differentiate between successful and unsuccessful group members.  In other words, the members who were unchanged or even had destructive experiences were as apt as successful members to value highly emotional incidents of the group.

      What types of experiences did differentiate the successful from the unsuccessful members? There was very clear evidence that a cognitive component was essential; the successful members either acquired information or personal insight. That these findings occur in groups led by leaders who did not attach much importance to the intellectual component speaks strongly for their being part of the core, and not the facade, of the change process.

Theory and Practice of Group Psychotherapy (253:29)

This research, then, returning to my four levels of change discussed at the beginning of this chapter, indicates that these encounter groups affected the participants strongly on the level of Attitude. Over two-thirds of the participants felt that they had had an interesting and successful experience. For a change in the deeper levels of Values and Emotions to take place in a manner helpful to the participants in a group, there must be understanding, caring, and a balance intensity of both emotional expression and structure.

            There is an enigma or contradiction in these statistics.  The percentages of people who reported that they had had a successful experience is significantly higher than the percentages of successes that were indicated by the more objective test scores and observations.  There are probably several factors that contribute to these variances.  A student who signs up and completes a course, or even takes a course for the experience or class credit, may find it interesting and stimulating but not change significantly in the process.  If a person becomes a member of a therapy group, on the other hand, and remains unchanged after a time (I am not specifying what is a reasonable amount of time.), this experience may be regarded as a failure considering the outlay of resources that is meant to lead to an improved life experience, and especially the mitigation of continued suffering that should be addressed in an immediate fashion.

            In a more ominous tone, this discrepency between perceived success and objectively measured success indicates that members of groups may ignore or overlook harmful effects due to a type of group contagion [Cf. Le Bon and McDougal references in Freud: Group Psychology and Analysis of the Ego, cited above in Chapter 1. Jung may even consider this process to be a type of “possession”. Jung is highly skeptical of a group’s therapeutic potential in general. Cf. his critical essays in Group Psychotherapy and Group Function (169)]. Consciously, group participants may remain interested or engaged while the process may not be to their benefit. This is one of the reasons that I return to the issue of a healthy group environment so often.

            Finally, people join groups for many different motives and may derive benefits in other areas that therapy and related research may not recognize or are too difficult to measure.  My purpose in looking at ingredients for a healthy change is to emphasize those aspects that can be identified and accentuated.

   
        

We may now extrapolate our information gained from this research.  Our descriptions of four factors contributing to positive outcomes in the Groups have been presented in terms of leadership function.  Using characteristics of a successful Group leader, as identified by Liebermann, Yalom, and Miles, we may describe the tone or optimal Group environment in which beneficial change occurs. The encounter Group research focuses primarily on these characteristics and behavior of the leaders. For our purposes, I will change the style of the research reports slightly.  From the original reports of leader behaviors I will take the liberty of extrapolating the tone of the Group with a beneficial environment for members. I refer specifically to the leaders only where it would be impossible or too complex to describe certain qualities in terms of Group environment.


As Caring within the Group increases, beneficial effectiveness increases. Group members offer one another: “…friendship, love, affection, and frequent invitations...to seek feedback as well as support, praise, and encouragement.”  Specific, definable, personal relationships are established.  Such adjectives as: giving, understanding, genuineness, caring, sympathy, warmth, openness, kindness are associated with this factor. A technical orientation is negatively associated to a Group with a highly caring environment (136:238). I would add, from my observations while leading Groups, that the experience of members providing Caring to other Group members has an important therapeutic value for provider as well as recipient.


Meaning Attribution involves cognitizing behavior and is also directly, linearly related to outcome. Members of a Group, while gaining in understanding also derive beneficial effects from their Group experience. Group members develop concepts and understanding about the Group process, their relationships to other members, and their own experiences. Understanding, explaining, clarifying, and interpreting, provide frameworks for change. Members look directly into experience to understand its meaning, and the feelings involved. Discussion such as interpretation or even simple observation of one another’s behavior and attitude takes place leading to reflective insight. Liebermann, Yalom, and Miles find that this factor has a dual property. Members learn about aspects of the Group along with insights about themselves as individuals:

…interpretations generally focus on the group as a whole emphasize cognitive recognition of group climate, how the group is working, and so forth. (Issues are) often raise(d)…or…the group (is asked) to reflect on its behavior—to take a cognitive or reflective stance toward group experiences…(Groups) who are high on Meaning-Attribution directed at individual behavior request a similar stance relative to interpersonal issues.

Encounter Groups: First Facts (136:238)

Members of the Group focus on the process of understanding who we are, what we do, how we interact, and how we feel. Behavior and feelings become better understood: individually, interpersonally, as well as relating to Group process. The Group experience is most fruitful if there is a trend from relative Group chaos toward understanding of clearly defined models of Group process for Group members. Group members discuss interaction and share the experiences of Group membership with one another. Interpersonal communications principles are discussed, practiced, and applied to interactions in the Group.  Individuals may work on personal therapy issues within the Group with the help of other Group members. Insights about both one’s self and Group interaction are examples of the type of Meaning Attribution that is associated with positive therapeutic change.    

The perception of members that leaders who do not assume this function are more like peers suggests the quality of parent, priest, or pedagogue may be associated with this dimension. Meaning-Attribution, however, does not have the emotional valence of charisma as seen from the leaders’ scores…where charisma is clearly on a separate dimension.

Encounter Groups: First Facts (136:238-239)


Group members find the conversation interesting, stimulating, and often challenging. There must be optimal level of Emotional Stimulation which is effective for the encouragement of constructive change. If the Group offers members too little of this factor lethargy takes over. If the Group is too highly charged, the process freezes with an overload of anxiety or anger and rage, although anger may be worked with directly as in Psychodrama or recognized as a source for direction of change as with Gus. Emotional Stimulation involves challenge, confrontation, and revelation of personal values, feelings, beliefs, and attitudes. Members are given a great deal of individual attention and are expected and encouraged to participate. There is a high level of exhortation, challenges toward release, risk taking, and self-revelation. Anger may be expressed but also warmth and love. Group process includes emotional release and risk taking. The emotionally stimulating leader is described as possessing charisma and may function as a model. (136:235-238). Group climate itself may have a special quality analogous to charisma for the members.


Group participation has a predictable structure, even though it can be surprising at times. Executive Function is also a characteristic that has a positive effect at an optimal level. While this factor is important for the maintenance of the Group, if overdone it can rigidify the process, stifling creativity and free expression. Group members set limits, suggesting or setting rules, norms, goals, managing time, stopping, blocking, interceding, managing direction of movement. Members invite participation. They question one another, suggest procedures for both the Group or the individual. Decision-making functions and problem solving procedures may be suggested. Release of emotion is encouraged. Actual emotional release is an example of Emotional Stimulation. In Groups high in Executive Function members ask one another to reflect on some action while other members of the Group interpret it. A Group high in Meaning-Attribution, on the other hand, encourage the individual who is the Group focus to interpret his or her own actions or reflect on their participation in Group process. Structured exercises and teacher orientation by the leader appears to lower Group effectiveness (136:239)—although in the Chapter 2 narrative accountsof the Groups [L, Y, & M (136:30)], Group #3 which was considered high success also had a very high number of structured exercises, along with humor and fun. Both self reflection and accurate Group or leader interpretation of members’ behavior are therapeutically effective. (Cf. description of accurate empathy in the next section.) An individual developing insight about themselves seems to have increasing benefits while Group confrontation or interpretation is helpful to a point but then can become decreasingly beneficial. Sometimes insight or inspiration may have high emotional energy, and communication of rage in Psychodrama or “primal” expression leading to Catharsis is promotion of healthful change. Research regarding psychotherapy effectiveness later in this chapter, indicates expression of high emotion between members who know and trust one another may be better understood and accepted than between relative strangers. Executive Function also maintains a safe environment to discuss personal issues that a member may feel vulnerable to share. Although the rules of the Group may be scrutinized by members, they also uphold the communicational structure as understood. Confusion about rules may be a source of therapeutic work. 2

Liebermann, Yalom, and Miles provide us with a wealth of information by which we may infer a Group environment that supports beneficial change. One point that they make about their research is that it is not necessarily indicative of psychotherapy Groups. Although some of the leaders were practitioners of psychotherapy, the groups were short term, lasting an academic quarter, and the participants were ‘taking’ the groups for class credit. Motivation for therapy involves other factors such as alleviation of felt discomfort, confusion regarding social relations and behavior,improved emotional health, and wish for improved life functioning (a goal shared with education) and improved relations with others. Psychotherapeutic approaches include recognition of focal issues or symptoms. In the final analysis therapy looks toward helping Group members change significant elements of their lives and ‘life styles’. With this in mind, I will next review research findings regarding psychotherapy outcome. We can use similar procedures of extrapolation to determine a healthy Group environment. Although the emphasis is slightly different, many of the findings coincide closely with the encounter group research.

            While there are many theories about the forces and processes that influence group members toward positive change, psychotherapy researchers Charles Truax and Robert Carkhuff [Toward Effective Counseling and Psychotherapy, (222)] cite a small number of studies indicating the actual effectiveness of group therapy, identifying features that promote positive change. They have, however, developed thorough reviews of psychotherapy research, its meaning in relation to different schools of therapy, and methodology leading to different approaches to the training of therapists. Although these researchers’ initial orientation is client-centered therapy, they have attempted to integrate other orientations including psychoanalytic, behavioral, trait-factor, vocational, and existential-humanistic theory and techniques. They present a number of comparisons between different schools and approaches to therapy, along with results of many surveys and questionairres to show how their “therapeutic ingrediants” relate favorably to many other approaches. The shortcoming in their studies, for our purposes, is that most of these studies are with individual therapy and only occasional studies of groups. Nevertheless, their findings are applicable to our purpose of establishing a beneficial group environment.

        Truax and Carkhuff begin their review of research identifying the effectiveness of helpful activities in therapy with a challenge by Eysenck, a researcher who questions whether psychotherapy is effective at all (63:697-725). Eysenck compares the rates of improvement of a population of neurotic patients who have had treatment with a matched population of neurotic people who were placed on a waiting list. He finds both groups to improve similarly (now come to be known as ‘waiting list cure’). He summarizes his findings:

•  When untreated neurotic control groups are compared with experimental groups of neurotic patients treated by psychotherapy, both groups recover to approximately the same extent.

•  When soldiers who have suffered a neurotic breakdown and have not received psychotherapy are compared with soldiers who have received psychotherapy, the chances of the two groups returning to duty are approximately equal.

•  When neurotic soldiers are separated from the service, their chances of recovery are not affected by their receiving or not receiving psychotherapy.

•  Civilian neurotics who are treated by psychotherapy recover or improve to approximately the same extent as similar neurotics receiving no psychotherapy.

•  Children suffering from emotional disorders treated by psychotherapy recover or improve to approximately the same extent as similar children not receiving psychotherapy.

•  Neurotic patients treated by means of psychotherapy based on learning theory improve slightly more quickly.

•  Neurotic patients treated by means of psychoanalytic psychotherapy do not improve more quickly than patients treated by means of eclectic therapy, and may improve less quickly when account is taken of the large proportion of patients breaking off treatment.

•  With the single exception of the psychotherapeutic methods based on learning theory, results of published research…suggest that the therapeutic effects of psychotherapy are small or non-existent, and do not in any demonstrable way add to the non-specific effects of routine medical treatment, or to such events as occur in the patients’ everyday experience.

Handbook of Abnormal Psychology (63:719-720)



       

Eysenck finds that the only measurable advantage to a person’s participation in psychotherapy is the speed of recovery, and this faster recovery takes place only in therapy based on learning theory. Truax and Carkhuff begin their review of psychotherapy outcome initially citing several research reports showing little improvement. Next, in contrast, they compare these findings with research that demonstrates positive change (222:6-22). These studies include a number of different techniques and also clients with different focal issues. Their research shows different types of improvement, while Eysenck’s cited research focuses primarily on treatment of neurosis. Such issues as anxiety, substance abuse, school success, social functioning, and psychosis are addressed by the research that Truax and Carkhuff review. These approaches include different techniques of therapy, are more specifically designed for varied symptoms, and at least some yield positive results in contrast to Eysenck. One example of a specialized approach to therapy, described in detail in the next chapter, has been developed since Esyenck’s study, by Vietnam War veterans forming ‘rap Groups’ to help one another re-enter American society. While Eysenck’s research presumably referred to the 1940s and 1950s, i. e. post World War II, Robert Jay Lifton’s research follows methods and processes that these veterans have found to be helpful, summerized in Chapter Three of this study. This is a particularly powerful Group process as it is composed of individuals who have had a common experience forming Groups with a sense of brotherhood and sisterhood, helping one another through a sometimes life threatening situation. Focal issues are relatively homogeneous with very high levels of Empathy, combining Warmth and Meaning Attribution. This is an example of an updated approach which is more specific in its focus than Eysenck’s. Since the time of Lifton’s book the diagnosis of Post Traumatic Stress Disorder (PTSD) has been developed. 3  Truax and Carkhuff conclude:


...after a careful review of the relevant research literature, it now appears that Eysenck was essentially correct in saying that the average counseling and psychotherapy as is currently practiced does not result in average client improvement greater than that observed in clients who receive no special counseling or psychotherapeutic treatment. (This is in spite of Eysenck’s inclusion of questionable data and indiscriminate pooling of data from reports with divergent criterian for treatment outcome.) Frank (65) and others have noted that statistical studies consistently report that about two-thirds of the neurotic patients improve immediately after treatment regardless of the type of psychotherapy received, but that the same improvement rate has been found for comparable clients who have not had psychotherapy. However, some relatively well-controlled studies show that certain counselors or therapists do produce beneficial effects beyond that observed in equivalent control groups.
Toward Effective Counseling and Psychotherapy (222:5)   

    

In other words, a highly skilled counselor or therapist can facilitate improvement for a significantly higher number of clients than the average, and average counseling and therapy is no better than none. Truax and Carkhuff combine this information to come to a startling conclusion:

Putting together these two bodies of evidence, it logically follows that if psychotherapy has no overall effect, but that there are valid specific instances where it is indeed effective, then there must also be specific instances in which it is harmful. That is, to achieve this average, if some clients have been helped, then other clients must have been harmed.

            Toward Effective Counseling and Psychotherapy (222:5)

These results and interpretation are in substantial agreement with the statistical research that Liebermann, Yalom, and Miles find with their encounter group survey. (Also in agreement, both research findings included evidence that these respective approaches to individual change had another similar significant effect. Some participants were moved from the middle, ‘No Change’ position toward improvement, but also failure for others.) We conclude, then, that a group may have harmful as well as beneficial effects on its members. It is not difficult to find examples in the newspaper or on TV of ‘groups’ that have proceeded over time to questionable, if not outright destructive stances to themselves and society. Manson’s Family, the S. L. A., Jonestown, Heaven’s Gate, the list can continue for far too long. From the opposite side of the social-political sphere, Irvin Janis has studied Groupthink, the situation where administrative groups have virtually talked themselves into pursuing public policy that has had disastrous results. The members are not trying to improve their own perspective; usually in these instances, they assume their own infallibility (108). (END NOTE 11 includes some operational principles to improve and safeguard against this situation. I would also refer back to the footnote #1 of this chapter. It may be an issue of semantics, but a true Group should refer to a Group with beneficial effects for its members. Crowd, mob, or herd dynamics operate when members are depersonalized and led toward alienated and sometimes destructive ends.) For our study we may, once again, identify healthful, creative qualities promoted within a Group and replace the focus on the individual therapist to a focus on the Group environment.

        Truax and Carkhuff isolate and study these qualities that successful therapists promote in their sessions. Not surprisingly, considering their initial client-centered orientation, they have developed three “Central Therapeutic Ingredients” which appear to be very close to conditions recommended by Carl Rogers in Client Centered Therapy and his other published studies (190, 191, 193,194, 195). They do review studies from a number of other clinical researchers who also identify these or similar conditions to lead to success. They clarify definitions and greatly expand their applications to other schools of therapy and training. They have also produced scales and behavioral descriptions with which we may judge the beneficial effectiveness of therapeutic interactions. We will return to these scales for examples. (Client centered therapy, as a technique, is not given any special treatment in these research summaries. Practitioners of the technique have both success and mixed results.) 4

The three Central Therapeutic Ingredients of an effective counseling-therapeutic relationship are:

•  Genuineness;

•  Non-possessive Warmth;

•  Accurate Empathy.


Truax and Carkhuff describe these therapeutic ingredients:

             

Genuineness (also referred to as ‘Congruence’) is a quality of interaction that describes honest communication. In genuine relationships, people generally say what they mean. There is a minimum of ulterior motive involved in the interaction. An attempt to lower facades is communicated. Defensiveness, rather than person-to-person interaction, is the antithesis of genuineness (222:23). Trust is a growing part of a genuine relationship.  

            Ethologists including Konrad Lorenz in his studies On Aggression (190, 191), Jane Goodall in her work with chimpanzees in the wild In the Shadow of Man (82), and originally Darwin, who developed the discipline in The Expression of Emotion in Man and Animals (47: 52-58, Chps. 2, 10, 12), have shown how posturing is indicative of fear or hostility. Often posturing is a method of establishing hierarchy and bullying. Jockeying for power may replace intimacy, although sometimes it may be a prelude to intimacy. Posturing as an initial interaction may develop into a more genuine communication. Gregory Bateson in Steps to an Ecology of Mind: “Theory of Play and Fantasy” (13), studies posturing as a developmental activity in which young animals learn to distinguish play from aggression. His focus is on the difference in the origins of ‘normal’ perception and perception and behavior of persons who have been diagnosed with schizophrenia. In the latter situation a patient has trouble distinguishing motives and meaning during communication with members of his or her immediate social group. Although ‘normal’ response to posturing may include mistrust or distaste, it does not result in mystification leading to dissociation and a radical misconstruing of others’ meanings and motives. Especially detrimental is the sense of self blame in response to the “double-bind”, discussed in more detail in later chapters.  


Non-Possessive Warmth is similar to positive regard that Group members develop toward one another. In a Group with high levels of non-possessive warmth, members feel that they are valued. Group members communicate the experience of love and being loved to one another. Members feel welcomed to the Group (222:34-38). 

        Warmth may be expressed actively as well as passively. In therapy or a Group with orientation toward growth there are expectations for improvement or change. These are processes that members develop together and work toward with each others’ assistance. Non-possessive warmth includes a positive set of values and concern for one another (222:34-38). Adler’s description of  working toward an “ideal of ultimate values” through a “mild barrage of questions” cited in the previous chapter comes to mind as an example. Group members are concerned about one another, not hostile or overly competitive in their motives. Members communicate concern and care when a Group member is in someway ‘stuck’ or making poor judgments. They may be challenging and even confrontational when a member needs a boost or help toward self care or improved perspective. The ‘non-possessive’ aspect refers to the non-authoritarian climate. Although members disagree, they do not have to ‘fall into line’ to be a member. Competition and disagreement certainly have their place in a Group that values members’ development, even as in children’s gangs (in Cooley’s and Addam’s meaning), neighborhoods, or families as emphasized in the previous chapter. Members are accepted, however, no matter what their response. Often in therapy sessions clients are encouraged to express anything that comes to mind or to ‘free associate’. Anything that they talk about is accepted and discussed with the exception of threats of violence with the intention of action. Limitations include legally (and ethically), that therapists are required to report crimes against minors. Also, serious threats of self harm would not be ignored. Personal concern for one anothers’ safety and health would seem to be a summary response embodying all three Ingredients. Therapy results partially from a degree of tension: while the Group members accept one another ‘unconditionally’ they are also trying to improve themselves and each other. The accepting presence of other members may be support while a person works out issues themselves.   

            While Warmth may be expressed unconditionally, the non-possessive aspect of this Ingredient is practiced with a balanced intensity. Practically, acceptence of a member’s behavior may have cetain limits. At one extreme, which we might call ‘possessive coldness’, a person is valued only for what he or she gives to another. This is a symbiotic interaction leading to exploitation. Economists write of people as ‘human capital’ or commodities, a type of depersonalization that promotes alienation and a sense of isolation. At the other extreme a person may be valued even when they engage in violent or destructive behavior. To accept antisocial behaviour unconditionally would be a type of license, not part of a healthy or therapeutic interaction. A. S. Neill, radical English educator, friend of Wilhelm Reich, uses a community model of responsibility and governance for his school Summerhill. Neil writes extensively about the difference between “freedom”, an experience promoting growth through personal responsibility, contrasting with “license”, a type of behavior with little responsibility toward others. While a student’s antisocial behavior is not accepted, and certain consequences may apply as in greater society, he or she is not rejected as a person [Summerhill (161)]. A student’s improvement may even be recognized. (This certainly expands the definition of unconditional acceptance, and may show there are certain debates in therapeutic literature. A particular treatment approach seems logical for a particular personality issue.) 

            Clieint centered and psychoanalytic therapies often proceed in a “nondirective” or free association manner. Empathetic reflecting and accepting by the therapist allows the development of internal awareness as can be seen in recordings of Rogers’ counseling sessions (Carl Rogers and Gloria on www.YouTube.com). The many comic-cynical comments in Woody Allen films about analyses ending years or even centuries later (if ever) are the results we all laugh at (ha ha!). Complete acceptance of a client’s approach has its place with people with cognitive organization and internally directive reality testing. But! having provided the initial mental health interview for many psychotic patients (individuals who were unable to explain where they were or how they got there, or even who they were) and people with personality disorders [Axis II DMS (6) especially Narcissistic, Borderline, Schizophreniform and Anti-Social Disorders], as well as persons manifesting various organic brain syndromes resulting from medical side effects, chemical use, even brain tumors (as was diagnosed in the E. R. where I sent them)—patients brought to the hospital or jail by police who are mainly interested in maintaining order and safety in the community, and my goal as a Crisis Intervention Counselor (see Chapter 6) to establish communication, evaluate the need of the client to be in the hospital or in a safe location in jail (if being arrested by police), with medical or psychiatric intervention, or safety and supports of friends or family if released, therapeutically helping them organize their thought and behavior, and plan for the next day or week, I have needed to structure the interview. While accepting them as a person, there are certain issues they must address such as: ‘Why did you end up here—having been brought or come on your own?’ And: ‘Are you going to take care of yourself and deal with the immediate situation? How? If not, there are people who will. Some probably more to your liking than others. Here are your options right now. How can we get you to where you need to be?’ (see “Hazard” Chapter 6) Counseling, therapy, and crisis intervention is a mansion with many rooms.


Empathy is central and necessary in healthy human communication. We do not understand one another unless we have some idea of what others are experiencing during conversation. Without sharing feeling or passion (empathy from the Greek: en pathos = with feeling or passion) we become mathematical, machine or computer-like. Too often, however, we accept a common, every day social level of empathy. We do not pay too much attention to what people say about their inner experiences, themselves, and their private worlds. Indeed, if we show too much interest we may be perceived as intrusive. This response would indicate that the person who we are addressing has mixed feelings about our motives. Without analyzing our own purposes and detailing an interpersonal phenomenology, this should underscore the need for accurate empathy as well as showing how warmth and genuineness are also needed. Truax and Carkhuff point out that accurate empathy has always been at the heart of therapy (222:39). Part of the reason that a client comes to therapy is that the therapist, as professional listener, gains and communicates back to the client a greater understanding of the client’s self than he or she experiences alone. This increased experience and sharing with another is part of the therapeutic process. In fact, a unique dimension of psychotherapy, both individual and Group, is empathy for experiences that may be uncomfortable or too sensitive to share in ‘normal’ discourse. In the Group all members ideally develop the ability to relate to what the other members experience. As this happens the experience of empathy is developed for us all. There is a sense of sharing our experience with each other. This can lead to a feeling of belonging and acceptance and promote encouragement toward developing and achieving goals of improvement and growth.

            George Herbert Mead, describing “Development of Mind” and “Genesis of Self”, summarized in the previous chapter, shows how empathetic processes are necessary ingredients of the individual’s ability to choose, processes that Group members experience during healthful, therapeutic development and transformation. Mead’s description will be recapped as an example of empathetic communication and development: “When this occurs the individual becomes self-conscious and has a mind; he becomes aware of his relations to that process as a whole, and to the other individuals participating in it with him...aware of that process as modified by the reactions and interactions of individuals—including himself—who are carrying it on...which enables the individual to take the attitude of the other toward himself... ” and of the self: “The self is something which has a development... (it) arises in the process of social experience and activity...develops in the given individual as a result of his relations to that process as a whole and to other individuals within that process...” (italics added T. K. W.) (154:134).
 

Truax and Carkhuff have studied counseling and therapy sessions closely. They particularly concentrate on clinicians whose clients show beneficial changes while in or following a series of sessions. For training purposes, they devise scored scales to measure the effectiveness of client-therapist interaction. In these scales, the lowest number indicates virtually no therapeutic value and a high potential for harm. An increasing score indicates increasing therapeutic effectiveness. As with previous research reports I have taken the liberty to paraphrase and modify descriptions as Group interaction while the original descriptions were usually based on individual therapy sessions. I also add a few elaborations from my own clinical experience. Interactions are described at the lowest, medium, and highest effectiveness, omitting intermediate steps. The numbers of the stages correspond to the scale developed by Truax and Carkhuff.

   Genuineness

  

Stage 1 – Group interaction is clearly defensive. What members say and what they do is not congruent. There may be a striking contradiction in voice qualities and non-verbal cues. (Examples may include defensive social games without awareness or concern for one another, or angry members ‘grilling’ a member ‘for their own good’ while their actual motives are to punish.)


Stage 3 – The meeting is formal and professional.  Communication is forced and implicitly defensive. This is ‘normal’ business or public communication.


Stage 5 – Members interact freely and deeply.  Communication is open.  Feelings of all types are expressed and welcomed.  Pleasant, painful, and contradictory feelings are attended to.  The members communicate their inner experiences to one another.

Toward Effective Counseling and Psychotherapy (222:68-72)


Non-Possessive Warmth


Stage 1 – The Group members actively offer advice and direction to one another, giving clearly negative regard. The attitude is one of ‘...this is best for you.’ The Group members are highly judgmental and consider themselves ‘responsible for others who may be the center of attention. Thought reform and authoritarian ‘groups’ demand personal confession of members’ failings in adopting the ‘correct’ behavior or ideas. Members are required to ‘fall into line’ without concern for their individuality or personal issues. Other viewpoints expressed in this study would question whether this should even be decribed as a ‘group’.


Stage 3 – Group members communicate care and concern for one another but the tone of the group is ‘semi-possessive’ of the members. Communication indicates that it is important that members behave in a certain, expected manner. “We’re okay as long as we follow the rules with predictable behavior.” Once again, this is normal public ‘acceptable’ behavior, in fact it may be more personal than the average ‘norm’. 


Stage 5 – Warmth without restriction is communicated between members. Each Group member experiences respect for rights of free choice and personal worth.  Members feel free to be themselves even if they are regressing, being defensive or expressing dislike or rejection.  Members freely share their joys and aspirations or their depressions and failures. Members enjoy one anothers’ fellowship.   The Introduction 5 offers examples of such caring. 

Toward Effective Counseling and Psychotherapy (222:58-68)

Necessary restrictions include a limiting of violence and an agreement of structure for the sake of communication. Obviously a Group would dissolve in chaos were all members, or even several, to regress or express rage all at once. Control, however, is administered in an attitude of regard, non-punitively.    Psychodrama, the topic of Chapter 4, is also a method of structuring for more violent expression in a safe environment, with warmth as well as playfulness. This type of control cross references to Yalom, Lieberman, and Miles description of Executive Function.  

 


Accurate Empathy


Stage 1 – Group members seem completely unaware of one another’s expressed feelings or at times even their presence. Response is not appropriate to the mood or content of statements. Members may appear bored, disinterested, or actively offering advice without taking account of response or receptiveness.


Stage 5 – Group members respond to more obviously expressed feelings and concepts. Although there is awareness of less obvious feelings, response tends to be inaccurate, mildly defensive, or of a probing or critical nature. Tone of communication is jarring and not completely satisfactory for participants. There may be misunderstanding or some confusion.


Stage 9 – Response is unerring in accuracy and intensity. There is no hesitation; understanding of the deepest emotion is communicated. Even as emotion and content shift, the entire Group functions together smoothly. Through the process, there is an expansion of understanding and elaboration of experience for Group members. Members feel encouraged to continue or ‘tell us more.’

Toward Effective Counseling and Psychotherapy (222:46-58)

 

The scales above demonstrate a Group process moving from little involvement or concern of members for one another, through a stage of common social communication, toward a full Group experience. In one of their few comments about Group therapy Truax and Carkhuff summarize the combination of these higher levels of Group experience under the title Group Cohesiveness. They cite research that indicates the presence of Group Cohesiveness to be crucial for members to change beneficially during their Group experience (222:119-120).

            Group Cohesiveness, then, is a term that brings together the effects and interplay of the three Central Therapeutic Ingredients as they develop within a Group. We see that these three Central Ingredients are not independent entities but rather affect one another closely. The presence of a high level of one Ingredient promotes the development of others. As I was reframing the scale descriptions to illustrate Group climate, I found that as I described each seperate Ingredient, I often needed to refer to the other Ingredients. 

            I would summarize the qualities of communication that Truax and Carkhuff identify as leading to health promoting Group Cohesiveness: Members interact freely and deeply with open communication, expressing feelings of all types: positive, negative, pleasant, painful and often contradictory. Inner experiences are attended to and discussed in a warm accepting environment. Each Group member experiences respect for rights of free choice and personal worth, feels free to be themselves even if they are regressing, being defensive, or expressing dislike or rejection. Members freely share their joys and aspirations or their depressions and failures. Members enjoy one anothers’ fellowship. Communication is unerring in accuracy and intensity with no hesiatation. Understanding of the deepest emotion is communicated and as emotion and content shift, the entire Group functions together smoothly. Through the process, there is an expansion of understanding and elaboration of experience for Group members. Members feel encouraged to continue and ‘Tell us more.’  


To show the flux of these Ingredients and how they benefit Group members, I will return to our three personal case studies: Gus, Carla, and Allen.

              When Gus was confronted by other members of the Group the interaction may easily have turned out badly. Because there was a high degree of Empathy that had been established in the Group, however, the confrontation was exactly the correct information and intensity to move Gus to reflect and attempt new, more socially oriented behavior in his life outside of the Group. If the level of Warmth had not been sufficient in the Group, Gus could have easily shrugged off the confrontation or become put-off by it; he could have left the Group. Both of these actions would have been the result of low Group Cohesiveness.

            Carla, on the other hand, did leave the Group for awhile at the suggestion and approval of the leader. This was a mutually agreed upon time-out due to the extreme stress and agitation that she experienced during Group sessions. This came to a head several weeks after she started attending the Group. Another student member seems to have been the explicit impetus for her leaving. Carla had related to the Group that she could not concentrate on her assignments. Whenever she sat down to study she started feeling so angry with a professor of one of her classes that she would involuntarily picture the instructor and start telling him what she thought of his assignment in very uncomplimentary terms. This rage would take over her concentration and interfere with her progress. She would also, during Group sessions, compulsively burst into vitriolic rants about students in her high school. Jan, a sophomore psychology major (Sometimes life imitates clinical clichés as well as art!), told Carla in what seemed to be a very concerned and personal manner, that her problems sounded like a case study of a patient who had been diagnosed with schizophrenia as presented in her, Jan’s, abnormal psychology course. Jan advised Carla to see a psychiatrist immediately. There was a good chance that she could be stabilized if not cured. The Group could superficially be rated high on Genuineness and Warmth. (Later, however, in Group discussion some issues of jealously and fear became more apparent in Jan’s motives.)

            Even Empathy has possibly been expressed at a higher level than may first have been obvious, considering Jan’s off-the-wall misdiagnosis. Carla had stated, in her first Group session, that she thought that she was schizophrenic, an equally amateur self-misdiagnosis. Occasionally, new participants in a group introduce themselves in overly dramatic, somewhat sarcastic terms like I’m schizophrenic! or I’m crazy as a loon! (Yes, I’ve heard this more than once, sometimes from members who have been at it awhile.) Usually this means that they feel somewhat disorganized, anxious, and extremely stressed-out, a common feeling for a person just beginning counseling. It is also possible that Carla was echoing a theme that was popular on campus at that time: that a schizophrenic episode leads to a transcendental experience and a type of enlightenment. Carla may have been identifying herself with this fad. In response, as Jan later explained, she was just trying to help Carla with this problem.

            Carla’s resulting panic was not at the thought of being mentally ill, as she discussed in subsequent private sessions, but at the idea of being in a situation with a man in absolute control of her life, particularly in a mental hospital with a male psychiatrist. Jan had effectively zeroed in on some of Carla’s deeper fears, this focusing being a high degree of partial Empathy. Neither person really understood what had happened and the emotional explosion that followed Jan’s comments was a surprise to all concerned. Over the course of her individual counseling sessions Carla worked out some of these complicated interactions and responses. These centered on dominant males in her life, initially the professor, then the doctors, and even men she had dated, as well as her brothers and her father. These interpersonal issues combined with family expectations of academic achievement, which seemed to be hitting the wall. This situation was creating a great deal of stress in Carla’s life. (“Carla” is a composite of summaries given by counselors-in-training during supervision, while they counseled student clients, both male and female. The issues and interaction reported actually took place, by various counselees, in Group where these interns were co-therapists or during individual sessions.) Initially, Carla seemed only vaguely conscious of these pressures and dynamics. While she temporarily left the Group she continued to see a female counselor who began working with her on the sources of this stress. As I have indicated, she later returned to the Group with her counselor’s encouragement and without psychiatric intervention and only a minor disruption of her studies. It was noted by other members that she did not seem to become as agitated as she had become previously. Initially she would start obsessively talking about herself, possibly revealing too much about her inner experience, too quickly. Now she could sit quietly while other members talked. The one-to-one counseling continued while she resumed the Group. Her individual counselor concentrated on a certain set of Empathetic Qualities while the Group focused on others. The individual counseling also included discussion about important confidential issues that were not discussed in the more public environment of Group.  

          Allen, in contrast, presents a very bare-bones approach to Group Cohesiveness. The Group he attends is not particularly high in Warmth, in fact at times it can appear rather critical and confrontational, even cruel. This may be hard to evaluate as it is largely made up of street-wise adolescents whose common language is always tinged with sarcasm and allusions to sex, drugs, violence, and, yes, rock and roll—these topics discussed especially in the presence of older adults and leaders, with sublimated, and often not so sublimated, anger in their direction. What appears harsh to an outsider may be a type of Empathy, the participants relating to one another’s life experiences. The main emphasis is on Genuineness. Life is described largely as a game, but Group members tell each other to “Drop all that bullshit and come clean.” Or, “Be real!” There is a framework of approach, within which the Group operates, based on Twelve-Step principles. As this structure and process has developed for treatment of alcohol and, later, drug abuse, it has what could be described as an internal wisdom, an Empathic Understanding summarizing the experience of members of A. A., then later N. A., over several decades. 6 Allen explains that he thinks this approach is a ‘game’ too, but it works in that it keeps him straight. Empathy, also in this case, means roughly seeing through other members’ rationalizations and telling them when they are using them. In the confrontation there seems to be an expression of understanding and concern. When Allen is depressed or angry, the other members will not let him withdraw or leave and take drugs. He does the same for them and recounting his experiences and successes helps him build his own strength and self worth. 

            The Group culture that I have described, including the Twelve-Step approach, and even the brutal Genuineness contribute to an Empathetic Understanding shared by Allen and his Group. The quality of Executive Function, also identified from the Stanford research, is very important for disturbed adolescents. Rational and consistent limits and rules can even be seen as an expression of Empathy and Warmth, a type of expression of caring and concern. Around issues such as drug and alcohol use and physical violence, Executive Function, partially expressed in the form of “House Rules”, is quite absolute and unbending: alcohol, substance use, and physical and verbal threats or actions are not allowed. Sometimes anger boils over, but these are issues to be discussed in community meetings or Group sessions. Violation becomes an issue for serious discussion and repeated violations may be a cause for restriction of privileges or even expulsion. Some group homes have even stricter policies. In this case this is therapeutically beneficial. Issues that residents have with these rules, which is a common and frequent theme for discussion in Group, are the basis of a therapeutic process of internalizing rational, healthy perspectives toward self-care. As was the case with Allen with his initial Group Home placement, these rules may also be imposed by outside authorities including juvenile probation and social welfare agencies, This situation provides a fruitful environment for the residents and staff to discuss ways to deal with anger and procedures to meet requirements imposed by impersonal forces, a fertile ground to learn self-care and self-control. (Cf Fritz Redl, When we deal with children and Understanding Children’s Behavior (188) 

            Residents of the half-way house where Allen lives can be observed showing interest and concern for each other on a daily basis during non-group interchanges and discussions. These day-to-day interaction can be high in therapeutic quality. Sometimes it appears that residents save their more dramatic interactions for the Group. This is a way of working on difficulties during Group time and practicing a more ‘normal’ life-style and interaction during residents’ free ‘living time’. This is one example of how a great deal more has taken place in the Groups of which Gus, Carla, and Allen were members, than the therapeutic change that I have focused on. Group members who were the basis for these case examples discussed and worked on family issues, interpersonal issues, universal and existential issues, developed a sense of hope, and Allen, especially, was given guidance, direction (sometimes more than he wanted), as well as education and tutoring by Group Home staff. I have concentrated on focal issues of each case study and this is an introduction to the next section of this chapter.





SUMMARY OF CLINICAL AND RESEARCH EVIDENCE


Yalom‘s Therapeutic Factors  7


Irvin Yalom organizes sections of his book, Theory and Practice of Group Psychotherapy (253:4), around eleven “Therapeutic Factors”. He sees these as descriptions of important dynamic qualities that take place in therapy groups. These “Factors” are:

  

•  Installation of Hope.

•  Universality.

•  Imparting Information.

•  Altruism.

•  Corrective Recapitulation of the Primary Family Group.

•  Development of Socializing Techniques.

•  Imitative Behavior.

•  Interpersonal Learning.

•  Group Cohesiveness.

•  Catharsis.

•  Existential Factors.


Although Yalom originally developed these “Factors” for therapy groups, their significance has wider application. Virtually all of these “Factors” are potentially present in any small group. While we attend to and focus on these “Factors” in therapy, they all exist in many other groups active in our communities and even our work. These groups, of which we are all members, are not specifically designated as therapeutic but certainly benefit, in important, meaningful ways, to our lives. Group membership, then, may contribute an unrecognized therapeutic effect regardless of the rationale for the group. With the present interest in community mental health, we should recognize that many types of groups have prophylactic as well as creative-developmental benefits for participants. (This is a point that Wallace McAfee and I came to as we discussed this recently published research.)

   

In this section these “Therapeutic Factors” are correlated with organizing points that have been emphasized in the theories and clinical research of this and the previous chapter:

           The theories of Freud, Fromm, Tillich, and Adler are reviewed to gain insight into social formations which are present in a group but yet extend to larger social organization. Freud emphasizes relationships with authority particularly Recapitulation of the Primary Family Group. He does not emphasize the small group in itself, but sees each member of a group as being held in tension or “identification” with the leader. The structure of the group reflects deeper unconscious motives including potential for violence—this maintained under control. In this organization Universality, Imparting of Information, Imitative Behavior, and limited type of Group Cohesiveness, focusing on the leader, all are present. Indeed, some psychoanalysts believe that therapeutic benefit comes only from members’ relationships with the leader and consequently de-emphasize member-to-member relationships. 8   Other psychoanalysts, notably Bion (20:166), see this as an avoidance of the potency of groups.

            Fromm, who writes as both a psychoanalyst and social critic, emphasizes society’s effects on the individual. He presents the matriarchal sources of group formation, contrasting the patriarchal “primal horde” with the mother-centered nurturing group. While this group is supportive of basic survival with a sense of acceptance and belonging, individual development may be ignored or restricted. It seems that Yalom has missed a significant curative factor by not including nurturance or a similar quality with his factors. Like many other therapeutic qualities, nurturance is incomplete alone. While the encounter group and counseling/psychotherapy research found Caring and Warmth to be strong promoters of healthful change—qualities that are grounds of sustenance in a Group, Meaning Attribution is another strong factor—not inherently part of the maternal group according to Fromm—promoting differentiation and individuation. In a related approach, the maternal therapeutic significance of being held is emphasized by pediatrician and child analyst Donald Winnicott who studies these qualities in analytic sessions. He sees the analyst, both male and female, as developing the transference role as Mother in the way that he or she establishes a “holding environment” for the analysand. The person of the analyst provides this environment while he or she also represents individuation. A Group with high levels of therapeutic qualities may create a similar effect. 9

          Tillich emphasizes Existential Factors , showing that the political organization of society as well as the structure of the group is based on members’ methods of coping with ontological anxieties arising from concerns about nonbeing . These issues are expressed both individually and organizationally, in the methods that group members participate-in-the-world, coming to structure their interactions and rituals, developing direction and meaning. Group functions as a microcosm that models culture for individual members. Anxiety, experienced by members relating to issues of being-nonbeing, is explored in an immediate fashion with other members of the Group. Installation of Hope, Universality, and Group Cohesiveness are factors present in this viewpoint.

          Adler identifies a therapeutic approach that he has named “social interest” as opposed to the more autistic positions of inferiority-superiority. He has clear therapeutic goals: helping the individual develop a reflective relationship in the “Ideal Community” where shortcomings will be re-evaluated and future, socially constructive behavior planned and carried out. Although he describes this interaction as with an individual therapist, the Group is a natural environment that can be developed for this process. Universality, Altruism, Development of Socializing Techniques are present in his therapeutic approach.

            With Mead’s social philosophy we move into actual member-to-member relationships that are present in the group. Interpersonal communication and interaction that characterize the small group actually begin to come into relief. This interaction between individuals ultimately stimulates each to membership as in the developmental game. Universality, Imparting of Information, Development of Socializing Techniques, Imitative Behavior, and Interpersonal Learning can be seen as related to his study. Another important factor promoted by interpersonal interaction, from Mead’s view, is the Installation of Hope, which, although not directly named, develops from a new perspective group members gain on their own behaviors and attitudes through reciprocal relations. This may be seen as the heart of group formation leading to greater choice and self control. Like Adler, members develop goals and direction through communication with others and come to reflect on their own behavior. Participants develop new, active approaches to thier lives. Interpersonal Learning may be considered the basis of these changes, but with the addition of heightened consciousness while developing reflective intelligence through observation of others gestures and complex social interaction in the form of roles and games. These roles and games seem to be summary factors or metafactors, each a gestalt made up from several of Yalom’s “Therapeutic Factors”. The human development framework gives us a model for therapeutic process and progress. Chapter Six, the development of the Crisis Intervention Counselor Workshop, demonstrates how this interpersonal development model provides a foundation and structure for teaching and learning of these therapeutic ingredients.

            Cooley defines a Primary Group. Universality, Imparting of Information, Recapitulation of the Family (the neighborhood should be included here), Socializing Techniques, Imitative Behavior, Interpersonal Learning, and Cohesiveness are component parts of the Primary Group. The group, as an entity, becomes defined with unique properties, not only a trend among others in society. Cooley’s perspective reinforces and dovetails nicely with Mead’s. He grounds understanding of group formation in the child’s experience of the family and then the neighborhood, giving direction for growth and maturity.

            From different perspectives, Frank and Oden review a the sources of encounter group procedures and techniques, comparing these group activities with procedures of older religious traditions. All of Yalom’s “Therapeutic Factors” including Catharsis, given little attention up to now, except possibly Konner’s description of !Kung San trance ritual that confers healing powers on select individuals, come into play in the group trends that they have studied. Catharsis will be given greater attention and described in depth in our upcoming description of Psychodrama.

            In the review of clinical reseach, the quality of interaction that should take place in a Group for positive therapeutic effect is studied. Yalom’s “Factors” were influenced and informed by this research.10   Four “leadership functions” come into view and are identified by the encounter group research, while three “Therapeutic Ingredients” are developed from therapist and counselor training research by Truax, Carkhuff, and, later, Berenson.

            Lieberman, Yalom, and Miles find that a Group atmosphere high in Caring and Meaning Attribution is directly associated with positive change. Emotional Stimulation and Executive Function are also important factors, but their presence in a group must be maintained at a balanced optimal range for maximum benefit.

          Truax and Carkhuff determine, from their research and reviews of research, that Group Cohesiveness is an important quality to be developed in therapy groups. To be effective, Group Cohesiveness must include three components: Genuineness, Non-Possessive Warmth , and Accurate Empathy. Yalom, while agreeing that these three components are important, points out that the encounter group studies that he and his colleagues did at Stanford show that Meaning Attribution is also vital and necessary for a group to have a healthy orientation. He criticizes the client-centered point of view as being incomplete:


Both emotional stimulation and cognitive structuring are essential. The Rogerian factors of empathy, genuineness, and unconditional positive regard thus seem incomplete; we must add the cognitive function of the leader.The research does not tell us what kind of meaning attribution as essential. (Both group process and interpersonal dynamic clarification seem useful.) What seems important is the process of explanation which, in a number of ways, enabled the participant to integrate his experience, to generalize from it, and to transport it into other life situations.


Theory and Practice of Group Psychotherapy (253:478)


In ending this review of research I would return to an enigma in the encounter group studies, specifically the successful tape Group. I believe that this Group demonstrates several factors that have been overlooked by previously cited authorities. The reasons may be clarified. Several clinicians with whom I have discussed this Group have expressed the belief that there was a covert leader. While this may have been true, it does not explain the Group culture that was developed by all members together. The narrative account of this Group does not indicate a covert leader (136:89-91). This Group was rebellious to authority, members had an ironic sense of humor, and were dissatisfied with the tape as leader. One of the members is quoted:“I’ll be damned if I’m going to let a machine tell me how to be more human“ (136:91). In contrast the other tape group had several failures, although the narrative tells a somewhat different account than the bare statistics: 2 negative changers, 0 casualties, but 3 moderate improvers (136:118). This Group was characterized as obedient: they followed the directions, and programmed warmth. (Actually this Group had some mixed-moderate success according to the narrative, and members were still friendly with one another in the follow-up (136:87-89). Both tape-led Group members remembered the names of the other members better than many other Groups (136:89). The members of the high success Group, in contrast, took responsibility for their own direction and Group tone. Extremely important, especially in light of Norman Cousin’s research on the healing properties of humor (43, 44), is that the members seemed to have fun! (Cousins also found that taking control of your own treatment in medical procedures is a powerful source of healing!). Notice how little these last factors seem to bubble to the surface. We authorities of clinical research rarely mention fun. It’s too close: the members running their own group and enjoying it! Questioning our august authority and knowledge! Counter-transference comes to mind, for those of a psychoanalytic view. Hopefully the next chapters will have a little humor, along with the more weighty issues. As alluded to previously, summary accounts such as Table 3-8 (136:118) and the detailed descriptions of the Groups in Chapter 2 (Liebermann, Yalom, & Miles) seem to tell different tales than the factor analysis. For instance: members of Group #3 [0 casualties, 2 moderate positive, 2 high learners (136:118)] are described as having fun—a good time along with cathartic pillow fights, as well being challenged. This barely shows in the correlations, if at all.  11   To quote the older English ladies in the Monty Python (an ultimate comedy Group!) TV sketch, deciding whether to watch “Dr. Bronowski on the telly....Bloody scientists! Take all the mystery out of life.”


NOTES      Chapter Two

1    Joline, and I have an ongoing discussion about some of Wallace McAfee’s ideas about Groups. She contends, agreeing with him, that a true Group is personal, all members being concerned with one another to the point where destructive and authoritarian attitudes would be viewed as pathological and not promoted by the Group as a whole. A cult would be the results of ‘crowd’-type of experience, rather than the affirming tone of a Group experience.  The ‘crowd’ is impersonal and herd-like such as described by Le Bon in the previous chapter. While a Group may have a leader, his or her values should be relatively clear and unambiguous. Membership involves personal development and integration along with Group interaction. Group values are developed and influenced by all members.


2   The four “leadership functions” interplay to synergize their individual effectiveness. This, of course, is the result of the complexity of human communication. For example, Group members who are not usually outgoing may be overwhelmed by the more gregarious members. If the Group environment is high in Warmth, Empathy or understanding of individuals, and Group process, with structure that includes all members, and is appropriately stimulating and challenging, these members will not be lost in the flow of conversation, but will be encouraged by other Group members to contribute their unique participation to Group interaction. Other examples of synergy can be seen in the various expressions of beneficial emotions such as Warmth. Warmth is expressed in different manners as a function of Caring or a function of Emotional Stimulation. Likewise interpretations are expressed differently leading to Meaning Attribution (“What do you think about this? How did this all come about?”) or as an Executive Function [“You seem uncertain (empathy?) about these issues. Please talk about this.”]. Likewise Warmth may be expressed as an expression e.g. “I’m so glad you’re here.” or with a great deal of Executive quality: “I’m concerned. I think it may help for you to talk about your issue.” Warmth may even be included as a function of the environment: rigid classroom seating, pillows on the floor, outside as a picnic or natural environment, even a campfire or fireplace. In the follow-up Carkhuff and Berenson also recognize that these Ingredients promote and synergize one another. They also warn that Genuineness with highly critical or negative regard, while sometimes promoting change, may also be alienating. Too deep a level of Empathy may also be perceived as intrusive. They recommend an introduction at Level 5 and a development of relationships toward Levels 6, 7, 8, 9 (These levels are discussed in the next section of this chapter). [Beyond Counseling and Therapy (31:8-20)].


3     While there are many accounts of therapy group approaches and anecdotal accounts of successes in the literature, statistical studies of group therapy outcomes are limited. Reasons for people coming to a counselor or a Group often vary and do not fall within the categories of immediately measurable successful change or failure. Examples would include a person who attends a vocational counseling group. He or she may make certain decisions regarding job preparation and search but not have measurable personality change or even an immediate reduction of stress. Over time however personal decisions are made that are beneficial if the counseling or Group is helpful. This, of course, can be called improvement, but the process is difficult to follow in a short period of time and the argument could be made that a person seeking employment or job training would continue with or without counseling. Measuring comparable job satisfaction over the course of years or a lifetime, and correlating it to counseling experience, is a daunting task. Techniques for reducing stress while practicing a job interview as well a rehearsal and improving presentation of self may be considered an educational function or counseling, but I would certainly consider part of this process to include psychotherapy. Another example of difficult evaluation would be a couple who sees a marriage counselor before marrying. They may not change significantly but learn techniques of communication that come in handy later on. If they decide to postpone marriage or even not marry, would this necessarily be considered a failure? These issues are matters of research technique or long term follow-up, even including discussion of definitions of ‘success’ or ‘failure’, and warrant whole studies in themselves. There are many instances when aquiring new information and learning sources for future approaches is extremely helpful but not easily measurable with personality type testing. In these cases “Transformation” whether in the Group, or in individual sessions, may be described as an educative function, a counseling function, or, in a more limited sense, a therapeutic function. All of these approaches seek goals of future success as exemplified by improved social functioning and emotional and cognitive enhancement of self. In Chapter 4, I refer to McAfee’s term of this process as “Becoming Fully Human” and Maslow’s description of the “Fully Developed Human” through Self Actualized creativity.

           Alvin R. Mahrer: Experiential Psycotherapy: Basic Practices, finds outcone studies very limited in understanding such issues as “...the relationships between patient conditions, therapist operations, and patient consequences.” (143:29-30). He describes about a dozen different areas of concern that outcome studies are often unable to delineate. My descriptions, case examples, and “extrapolations” are meant to fill this void.

            In my own practice I have had many clients request help with habit control (usually smoking or over eating), school and study difficulties, especially concentration issues, air-flight, job interview types of anxieties and anxieties regarding medical treatment, for instance. I practice and teach hypnosis, self-hypnosis, guided fantasy and progressive relaxation techniques, meditation and mindfulness, autogenic training, for instance. Part of a session may be tailoring an approach and practicing. I often make tapes (now CDs) of sessions for listening by clients and even insist that they listen on their own. Difficulty doing this may be resistance and becomes a focus of therapy; only a small amount of time is usually spent discussing what may be called sub- or pre-conscious issues which psychotherapy would include, such as sources from life history, life style, and social stresses. McAfee taught that a short but insightful discussion centering on developmental conflicts at the right time has a major effect in theapy. While it may be argued that many individuals achieve these same goals on their own (Waiting list cures?—living longer and improved health is a very powerful motivator to quit smoking on its own.) I draw an analogy to a coach in athletics or a music teacher: there is a great deal you can and must do on your own, but a skilled observer-helper will show you approaches, even by critique, that you don’t necessarily know youself.


4    Carl Rogers has published his research about groups in On Encounter Groups (193). He identifies stages by which Group members become involved with the process. Members describe Group climate through testimonial and antecdote. Groups with high Emotional Stimulation and Caring which is similar to Non-Possessive Warmth, are described. Members of Rogers’ Groups seem to continually wrestle with the issues of Genuineness and Rogers’ other favored trait of Empathy. In other published studies of individual counseling and therapy Rogers has developed objective scales and tests to research the relation between activities of the therapist and outcomes. Truax, Carkhuff, and Berenson are heavily influenced in their approach by Rogers.


5    Cf. the first several sections of the Introduction above for portrayals of examples of Therapeutic Ingredients in action. Ronald Laing’s son Adrian presents a dramatic example of his father’s radical practice of these therapeutic factors or ingredients: During a lecture tour of the United States in 1972, at the Chicago Medical Center, Laing was asked to examine a young girl diagnosed with schizophrenia. She was naked in a room rocking. “Without warning he stripped off naked and entered her room. There he sat with her, rocking in time with her rhythm. After about twenty minutes she started talking to Ronnie—something she had not done since being admitted several months previously. The doctors were stunned. ‘Did it never occur to you to do that?’ Ronnie enquired afterward, with mischeivious innocence.” (R. D. Laing: a Biography (126:157) (Empathy, Warmth and Caring, Genuineness, even Meaning Attribution? or just very intense personal interaction and communication!)


6   Twelve-Step programs refer to approaches derived from Alcoholics Anonymous. Each step is a presentation of issues to identify, to gain a new perspective about, and to work on. It provides a graded map toward control of addictive behavior, self care, and a socially oriented life-style. The First Step challenges the new member with a confession of inability to control behavior and reliance on a “Higher Power” which although often controversial, may include reliance on the Group. This is a type of Universality. the “steps”, in the case of this particular adolescent half-way house, have been modified for adolescents and include issues broader than alcohol and drugs such as criminality, violence, etc. The advisory board, which includes clinicians and physicians, has, in their opinions, adapted the “steps” for the needs of the cliental, a procedure recommended by A. A. Cf. Introduction of this study, particularly the brief history of Group therapy derived from Pratt’s T. B. class, and the section that focuses on Wallace McAfee’s research in the next chapter. At the time of the original writing, it is possible that interactions were more confrontational than later approaches as the “Synanon Game” was being experimented with in Southern California and was popular in some encounter groups and residential treatment programs particularly dealing with drug abuse; this was before that organization’s demise. Some of this approach still survives in militaristic conditions of some parole early release programs. I have had to counsel with a number of failures on their return to jail as a Crisis Intervention specialist. I am aware of the manipulative behavior of many hard-drug users as well as prisoners, but there are points where they still need human comforting or at least time to vent.


7    Yalom initially named these qualities “Curative Factors.” In the most recent edition of his book, Yalom has changed their name to “Therapeutic Factors” (222:3). The reader is referred to the 4th edition for discussion. This has interesting implications about how the way views about the dynamics of therapy change over time.


8    Shafer and Galinsky review the psychoanalytic therapy group: Models of Group Therapy and Sensitivity Training (206:Chapter 3): “…many would argue that…psychoanalysis must always have the individual man, and his unconscious, a central core of its concern. As a result, practitioners of the present model (group psychoanalysis)…claim they do not treat groups per se…but instead treat an individual patient…this time in the presence of other individual patients…also being treated by him.” (206:49-50). Wolf, Katush, and Nattland [The Primacy of the Individual in Psychoanalysis Groups (249) point out that while group psychoanalysis has the goal of helping the individual member strengthen his or her ego, the group can interfere with this process by developing “themes” in which all members are expected to participate. On the other hand, the group, in this way, presents an environment, in contrast to which members can exercise their individuality. This provides a background and stimulus for the analyst’s interpretations. The group also presents a counter to the leader, encouraging individualization in relation to the analyst. Group members often are better with encouragement for each other toward certain insights as in Groups of hospitalized patients where fellow patients seem to have higher levels of Empathy for one another’s experiences and situations. Certain types of suggestions and even confrontations are better understood between patients.


9    Winnicott and his associates make a point that this experience is part of the transference in adult analysis as well as with children. ”Holding” refers to a communicational, emotional action. This is not physical holding, although physical holding is not uncommon in sensitivity training and encounter groups (Cf. Introduction for example.). There are interesting corollaries to “holding” as an activity or quality promoting growth. In Timaeus, Plato describes the cosmos as a container in which the universe is created. I often describe the Group as a “crucible”, a metaphor for a location where personal and interpersonal developmental processes are supported. While I was influenced by my work during college as a metallurgist and analytic chemist, Jung, in his alchemical studies, identifies the crucible as well as several other types of containers (ovens, baths, even sarcophagi, and, of course the womb) as being locations for important transformations. It also seems that the ‘Dasein’, (German: being there), the sense of being in an environment or location, the central issue of the philosophy of Heidegger in Being and Time, is a summary name for our sense of location: being-in-the-world. Many Native American rituals include the reference to a transforming enclosed space. Black Elk: The Sacred Pipe (20) sees the bowl of the sacred pipe as symbol of the bonfire, the circle of participants, and the glow of the coal as enlightened consciousness and common communicational experience. There are also kiva ceremonies of Pueblo and, historically, Anasazi, as well as sweat lodge ceremonies practiced by many Native American groups including religious ceremonies even by Native American prisoners in California (CDCR). These religious-ceremonial-vision Groups meet in many types of enclosed spaces: kivas, tipis, lodges. Carlos Castaneda (35) describes the fire and darkness creating a sense of enclosure. While he refers to a house, he is vague about the exact location of the ceremony of a group resembling the Native-American church of Northern Mexico and the American Southwest. Joseph Campbell (26) and Susanne K. Langer (124, 125) compare probable psychological-emotional effect of the art and ceremonies held within the paleolithic era caves of Central Europe with the interior décor of the cathedrals on the surface of the Earth of Europe—the encouragement of religious consciousness.


10    “Therapeutc Factors” seem to be general statements referring to “leadership functions” taking into account more specific trends which were identified in the Stanford Encounter Group study. Recapitulation of the Primary Family Group is a “Factor” which deserves more discussion than it receives in the body of this study. Yalom’s commentary gives both indication of its importance and description of how it is underestimated as a vital factor by group participants: “Family reenactment, or the corrective recapitulation of the primary family group experience, a curative factor highly valued by many therapists, is not considered helpful by group patients…Nor did the encounter group members value this factor highly. However, it is of interest to note that only the successful encounter group members cite this factor as important (Italics added, T. K. W.). The fact that this factor is not cited often by patients, though, should not surprise us since the factor is one which 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 which relentlessly haunts the group therapy room. The patient’s experience in his primary family obviously will, to a great degree, determine the nature of his parataxic distortions, the role he assumes in the group, his attitudes toward the group leaders, etc.” (253:97).


11   There are several other “Factors” and procedures that are important to discuss leading to a healthier or more productive group environment. Research is incomplete and only hints at their significance. Truax and Carkhuff identify Depth of Intrapersonal Exploration as a therapeutic factor of which that they could not quite gain statistical proof, although it seems intuitively clear that keeping the topic on track and relevant to clients’ development of self awareness is fairly important. They also study the therapeutic impact of varying the intensity of these “Factors” (222:Ch. 3). As presented in the main body of this chapter, Liebermann, Yalom, and Miles find self exploration and Group process awareness to be statistically important for members’ positive change (253). Hammond, Hepworth, and Smith Improving Therapeutic Effectiveness (94) discuss confrontation. They point out the this factor has a great deal of power but also may interfere with processes such as trust. It is dependent on motives, accuracy, timing, and other judgments of the therapist or leader; also important to the perspective toward Groups that I have attempted to develop, the relationships with fellow Group members . For instance: “You’ve been talking about this issue for several weeks (months, years?) now. How about planning out a way to change the situation?” vs. “You’re just b.s.ing us all. Stop your round and round. Get off your ass and do something!” The latter might be effective in a Group with trusted friends—and has actually been heard in such—or it may be devastating criticism in a Group with less group coherence. Insight and depth may also be attempted—another member states: “When you started the Group you said you were trapped by your parents. Now you have us trapped with your ‘Why don’t you?—yes, but.’ game. You’re just trying to punish us and piss us all off instead of your parents. Well you’ve succeeded. You just turn everyone into your personal prison. Stop it!!” H., H, and S. also study the middle phase of therapy, where much of the work takes place. Most clinician seem to like to describe the heroic events: that brilliant insightful interpretation (like this comment) or process of opening involvement. We all have egos too!

           In a slightly different vector Irving Janis studies administrative groups, forming public policy, whose members have taken themselves in disastrous directions Groupthink (108). He recommends several principles to correct this cult-like skew: 1) The leader should assign each member to be a critical evaluator and time is set aside to share these critiques. 2) When assigning a topic, the leader maintains an impartial stance in regard to where the study will proceed, this being determined by the members. 3) Subgroups with different leaders should be formed. 4) After policy has been formed the group is divided into two groups to evaluate the policy and reform and discuss differences. 5) Each member should discuss the policy decisions being developed with a trusted outside consultant. 6) Outside consultants who are familiar with the topic should periodically be invited to the Group to share their perspectives. 7) At every meeting meant to evaluate the Group policy, at least one member should be assigned as devil’s advocate. (108:262-267).

           The detailed descriptions in Chapter 2 seem to show different emphasis in some instances than the factor analysis. Reading these summaries is an education in Group Transformation itself. Along with successful Group #3, mentioned in the text, Group #8 was balanced, with a leader (TA and gestalt techniques) who was an “expert bundle of happiness” (138:51). Once again, positive affect. Sometimes therapy is not that mysterious, although needing a good deal of practice (and personal growth?) to accomplish!


Additional Comments on Encounter Group Research


Comparing the statistical correlations with the narrative descriptions raises questions but also gives hints for new directions to study. Grouip #5 and #6 were Psychodrama oriented. One led by a psychiatrist, the other by a leader described as having the least clinical credentials. They both had casualties and/or negative changers, but also successes and high learners. #5 leader was the most active and confrontational. It might be speculated that the high risk approaches were beneficial to some members but dangerous for others. Psychodrama is a technique that is explained in detail in Chapter 4 of this study. It is practiced as a therapeutic technique, and although can be effective as education in difficult situations and with difficult people, I would only involve a person in highly cathartic interactions if there was a commitment to follow-up and I would use diagnostic discretion. What may be a casualty in a limited time Group may also be a surfacing of issues that are addressed in the future follow-up or longer term therapy. The difference between a therapy Group and an encounter group where stated goals may be educational, i. e. class credit (hopefully learn something, too) the therapist would have some awareness of a member deteriorating of becoming emotionally overwhelmed and follow through.


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