Chapter 2 INTERPERSONAL LEARNING Interpersonal learnin

Chapter 2
INTERPERSONAL LEARNING
Interpersonal learning, as I define it, is a broad and complex
therapeu-tic factor. It is the group therapy analogue of
important therapeutic
factors in individual therapy such as insight, working through
the trans-
ference, and the corrective emotional experience. But it also
represents
processes unique to the group setting that unfold only as a
result of spe-
cific work on the part of the therapist. To define the concept of
interper-
sonal learning and to describe the mechanism whereby it
mediates
therapeutic change in the individual, I first need to discuss three
other
concepts:
1. The importance of interpersonal relationships
2. The corrective emotional experience
3. The group as social microcosm
THE IMPORTANCE OF
INTERPERSONAL RELATIONSHIPS
From whatever perspective we study human society-whether we
scan
humanity's broad evolutionary history or scrutinize the
development of

the single individual-we are at all times obliged to consider the
human
being in the matrix of his or her interpersonal relationships.
There is
convincing data from the study of nonhuman primates, primitive
human
cultures, and contemporary society that human beings have
always lived
in groups that have been characterized by intense and persistent
relarion-
ships among members and that the need to belong is a powerful,
funda-
mental, and pervasive motivation.' Interpersonal relatedness has
clearly
been adaptive in an evolutionary sense: without deep, positive,
reciprocal
interpersonal bonds, neither individual nor species survival
would have
been possible.
19
20 INTERPERSONAL LEARNING
John Bowlby, from his studies of the early mother-child
relationship,
concludes not only that attachment behavior is necessary for
survival but
also that it is core, intrinsic, and genetically built in.2 If mother
and infant
are separated, both experience marked anxiety concomitant with
their
search for the lost object. If the separ:ltion is prolonged, the
consequences

for the infant will be profound. Winnicott similarly noted,
"There is no
such thing as a baby. There exists a mother-infant pair."3 We
live in a "re-
lational matrix," according to Mitchell: "The person is
comprehensible
only within this tapestry of relationships, past and present."4
Similarly, a century ago the great American psychologist-
philosopher
William James said:
We are not only gregarious animals liking to be in sight of our
fellows,
but we have an innate propensity to get ourselves noticed, and
noticed fa-
vorably, by our kind. No more fiendish punishment could be
devised,
were such a thing physically possible, than that one should be
turned
loose in society and remain absolutely unnoticed by all the
members
thereof.5
Indeed, James's speculations have been substantiated time and
again by
contemporary research that documents the pain and the adverse
conse-
quences of loneliness. There is, for example, persuasive
evidence that the
rate for virtually every major cause of death is significantly
higher for the
lonely, the single, the divorced, and the widowed. 6 Social
isolation is as
much a risk factor for early mortality as obvious physical risk
factors such

as smoking and obesity.7 The inverse is also true: social
connection and in-
tegration have a positive impact on the course of serious
illnesses such as
cancer and AIDS. 8
Recognizing the primacy of relatedness and attachment,
contemporary
models of dynamic psychotherapy have evolved from a drive-
based, one-
person Freudian psychology to a two-person relational
psychology that
places the client's interpersonal experience at the center of
effective psy-
chotherapy.t9 Contemporary psychotherapy employs "a
relational model
in which mind is envisioned as built out of interactional
configurations of
self in relation to others." 10
Building on the earlier contributions of Harry Stack Sullivan
and his
interpersonal theory of psychiatry, 11 interpersonal models of
psychother-
apy have become prominent. 12 Although Sullivan's work was
seminally
important, contemporary generations of therapists rarely read
him. For
one thing, his language is often obscure (though there are
excellent ren-
derings of his work into plain English); 13 for another, his work
has so per-
vaded contemporary psychother apeutic thought that his original
writings
seem overly familiar or obvious. However, with the recent focus
on inte-

https://prominent.12
https://chotherapy.t9
21 The Importance of Interpersonal Relationships
grating cognitive and interpersonal approaches in individual
therapy and
in group therapy, interest in his contributions has resurged. 14
Kiesler ar-
gues in fact that the interpersonal frame is the most appropriate
model
within which therapists can meaningfully synthesize cognitive,
behav-
ioral, and psychodynamic approaches-it is the most
comprehensive of
the integrative psychotherapies.t15
Sullivan's formulations are exceedingly helpful for
understanding the
group therapeutic process. Although a comprehensive
discussion of inter-
personal theory is beyond the scope of this book, I will describe
a few key
concepts here. Sullivan contends that the personality is almost
entirely the
product of interaction with other significant human beings. The
need to
be closely related to others is as basic as any biological need
and is, in the
light of the prolonged period of helpless infancy, equally
necessary to sur-
vival. The developing child, in the quest for security, tends to
cultivate and
to emphasize those traits and aspects of the self that meet with

approval
and to squelch or deny those that meet with disapproval.
Eventually the
individual develops a concept of the self based on these
perceived ap-
praisals of significant others.
The self may be said to be made up of reflected appraisals. If
these were
chiefly derogatory, as in the case of an unwanted child who was
never
loved, of a child who has fallen into the hands of foster parents
who have
no real interest in him as a child; as I say, if the self-dynamism
is made up
of experience which is chiefly derogatory, it will facilitate
hostile, dis-
paraging appraisals of other people and it will entertain
disparaging and
hostile appraisals of itself. 16
This process of constructing our self-regard on the basis of
reflected
appraisals that we read in the eyes of important others
continues, of
course, through the developmental cycle. Grunebaum and
Solomon, in
their study of adolescents, have stressed that satisfying peer
relationships
and self-esteem are inseparable concepts.17 The same is true for
the el-
derly-we never outgrow the need for meaningful relatedness. 18
Sullivan used the term "parataxic distortions" to describe
individuals'
proclivity to distort their perceptions of others. A parataxic

distortion oc-
curs in an interpersonal situation when one person relates to
another not
on the basis of the realistic attributes of the other but on the
basis of a
personification existing chiefly in the farmer's own fantasy.
Although
parataxic distortion. is similar to the concept of transference, it
differs in
two important ways. First, the scope is broader: it refers not
only to an in-
dividual's distorted view of the therapist but to all interpersonal
relation-
ships (including, of course, distorted relationships among group
members). Second, the theory of origin is broader: parataxic
distortion is
https://relatedness.18
https://concepts.17
https://itself.16
https://resurged.14
constituted not only of the simple transferring onto
contemporary rela-
tionships of attitudes toward real-life figures of the past but
also of the
distortion of interpersonal reality in response to intrapersonal
needs. I
will generally use the two terms interchangeably; despite the
imputed dif-
ference in origins, transference and parataxic distortion may be
consid-
ered operationally identical. Furthermore, many therapists today

use the
term transference to refer to all interpersonal distortions rather
than con-
fining its use to the client-therapist relationship (see chapter 7).
The transference distortions emerge from a set of deeply stored
memo-
ries of early interactional experiences. 19 These memories
contribute to the
construction of an internal working model that shapes the
individual's at-
tachment patterns throughout life. 20 This internal working
model also
known as a schema21 consists of the individual's beliefs about
himself, the
way he makes sense of relationship cues, and the ensuing
interpersonal
behavior-not only his own but the type of behavior he draws
from oth-
ers.22 For instance, a young woman who grows up with
depressed and
overburdened parents is likely to feel that if she is to stay
connected and
attached to others, she must make no demands, suppress her
indepen-
dence, and subordinate herself to the emotional needs of others.t
Psy-
chotherapy may present her first opportunity to disconfirm her
rigid and
limiting interpersonal road map.
Interpersonal (that is, parataxic) distortions tend to be self-
perpetuat-
ing. For example, an individual with a derogatory, debased self-
image
may, through selective inattention or projection, incorrectly

perceive an-
other to be harsh and rejecting. Moreover, the process
compounds itself
because that individual may then gradually develop mannerisms
and be-
havioral traits-for example, servility, defensive antagonism, or
conde-
scension-that eventually will cause others to become, in reality,
harsh
and rejecting. This sequence is commonly referred to as a "self-
fulfilling
prophecy"-the individual anticipates that others will respond in
a cer-
tain manner and then unwittingly behaves in a manner that
brings that to
pass. In other words, causality in relationships is circular and
not linear.
Interpersonal research supports this thesis by demonstrating that
one's in-
terpersonal beliefs express themselves in behaviors that have a
predictable
impact on others. 23
Interpersonal distortions, in Sullivan's view, are modifiable
primarily
through consensual validation-that is, through comparing one's
inter-
personal evaluations with those of others. Consensual validation
is a par-
ticularly important concept in group therapy. Not infrequently a
group
member alters distortions after checking out the other members'
views of
some important incident.
This brings us to Sullivan's view of the therapeutic process. He

suggests
that the proper focus of research in mental health is the study of
processes
https://others.23
https://experiences.19
23 The Importance of Interpersonal Relationships
that involve or go on between people. 24 Mental disorder, or
psychiatric
symptomatology in all its varied manifestations, should be
translated into
interpersonal terms and treated accordingly.25 Current
psychotherapies
for many disorders emphasize this principle.t "Mental disorder"
also
consists of interpersonal processes that are either inadequate to
the social
situation or excessively complex because the individual is
relating to oth-
ers not only as they are but also in terms of distorted images
based on
who they represent from the past. Maladaptive interpersonal
behavior can
be further defined by its rigidity, extremism, distortion,
circularity, and its
seeming inescapability. 26
Accordingly, psychiatric treatment should be directed toward
the cor-
rection of interpersonal distortions, thus enabling the individual
to lead a
more abundant life, to participate collaboratively with others, to
obtain

interpersonal satisfactions in the context of realistic, mutually
satisfying
interpersonal relationships: "One achieves mental health to the
extent
that one becomes aware of one's interpersonal relationships. "
27 Psychi-
atric cure is the "expanding of the self to such final effect that
the patient
as known to himself is much the same person as the patient
behaving to
others." 28 Although core negative beliefs about oneself do not
disappear
totally with treatment, effective treatment generates a capacity
for inter-
personal mastery29 such that the client can respond with a
broadened,
flexible, empathetic, and more adaptive repertoire of behaviors,
replacing
vicious cycles with constructive ones.
Improving interpersonal communication is the focus of a range
of par-
ent and child group psychotherapy interventions that address
childhood
conduct disorders and antisocial behavior. Poor communication
of chil-
dren's needs and of parental expectations generates feelings of
personal
helplessness and ineffectiveness in both children and parents.
These lead
to the children's acting-out behaviors as well as to parental
responses that
are often hostile, devaluing, and inadvertently inflammatory. 30
In these
groups, parents and children learn to recognize and correct
maladaptive

interpersonal cycles through the use of psychoeducation,
problem solv-
ing, interpersonal skills training, role-playing, and feedback.
These ideas-that therapy is broadly interpersonal, both in its
goals
and in its means-are exceedingly germane to group therapy.
That does
not mean that all, or even most, clients entering group therapy
ask explic-
itly for help in their interpersonal relationships. Yet I have
observed that
the therapeutic goals of clients often undergo a shift after a
number of ses-
sions. Their initial goal, relief of suffering, is modified and
eventually re-
placed by new goals, usually interpersonal in nature. For
example, goals
may change from wanting relief from anxiety or depression to
wanting to
learn to communicate with others, to be more trusting and
honest with
others, to learn to love. In the brief group therapies, this
translation of
https://inflammatory.30
https://inescapability.26
https://accordingly.25
https://people.24
client concerns and aspirations into interpersonal ones may need
to take
place earlier, at the assessment and preparation phase (see

chapter 10).3 l
The goal shift from relief of suffering to change in interpersonal
func-
tioning is an essential early step in the dynamic therapeutic
process. It is
important in the thinking of the therapist as well. Therapists
cannot, for
example, treat depression per se: depression offers no effective
therapeu-
tic handhold, no rationale for examining interpersonal
relationships,
which, as I hope to demonstrate, is the key to the therapeutic
power of the
therapy group. It is necessary, first, to translate depression into
interper-
sonal terms and then to treat the underlying interpersonal
pathology.
Thus, the therapist translates depression into its interpersonal
issues-for
example, passive dependency, isolation, obsequiousness,
inability to ex-
press anger, hypersensitivity to separation-and then addresses
those in-
terpersonal issues in therapy.
Sullivan's statement of the overall process and goals of
individual ther-
apy is deeply consistent with those of interactional group
therapy. This
interpersonal and relational focus is a defining strength of
group therapy.t
The emphasis on the client's understanding of the past, of the
genetic de-
velopment of those maladaptive interpersonal stances, may be
less crucial

in group therapy than in the individual setting where Sullivan
worked (see
chapter 6).
The theory of interpersonal relationships has become so much
an inte-
gral part of the fabric of psychiatric thought that it needs no
further un-
derscoring. People need people-for initial and continued
survival, for
socialization, for the pursuit of satisfaction. No one-not the
dying, not
the outcast, not the mighty-transcends the need for human
contact.
During my many years of leading groups of individuals who all
had
some advanced form of cancer, 32 I was repeatedly struck by
the realization
that, in the face of death, we dread not so much nonbeing or
nothingness
but the accompanying utter loneliness. Dying patients may be
haunted by
interpersonal concerns-about being abandoned, for example,
even
shunned, by the world of the living. One woman, for example,
had
planned to give a large evening social function and learned that
very
morning that her cancer, heretofore believed contained, had
metastasized.
She kept the information secret and gave the party, all the while
dwelling
on the horrible thought that the pain from her disease would
eventually
grow so unbearable that she would become less human and,

finally, unac-
ceptable to others.
The isolation of the dying is often double-edged. Patients
themselves
often avoid those they most cherish, fearing that they will drag
their fam-
ily and friends into the quagmire of their despair. Thus they
avoid morbid
talk, develop an airy, cheery facade, and keep their fears to
themselves.
Their friends and family contribute to the isolation by pulling
back, by
25 The Impurtance of Interpersonal Relationships
not knowing how to speak to the dying, by not wanting to upset
them or
themselves. I agree with Elisabeth Kubler-Ross that the
question is not
whether but how to tell a patient openly and honestly about a
fatal illness.
The patient is always informed covertly that he or she is dying
by the de-
meanor, by the shrinking away, of the living. 33
Physicians often add to the isolation by keeping patients with
advanced
cancer at a considerable psychological distance-perhaps to
avoid their
sense of failure and futility, perhaps also to avoid dread of their
own
death. They make the mistake of concluding that, after all, there
is noth-

ing more they can do. Yet from the patient's standpoint, this is
the very
time when the physician is needed the most, not for technical
aid but for
sheer human presence. What the patient needs is to make
contact, to be
able to touch others, to voice concerns openly, to be reminded
that he or
she is not only apart from but also a part of. Psychotherapeutic
ap-
proaches are beginning to address these specific concerns of the
termi-
nally ill-their fear of isolation and their desire to retain dignity
within
their relationships.t Consider the outcasts-those individuals
thought to
be so inured to rejection that their interpersonal needs have
become heav-
ily calloused. The outcasts, too, have compelling social needs. I
once had
an experience in a prison that provided me with a forceful
reminder of the
ubiquitous nature of this human need. An untrained psychiatric
techni-
cian consulted me about his therapy group, composed of twelve
inmates.
The members of the group were all hardened recidivists, whose
offenses
ranged from aggressive sexual violation of a minor to murder.
The group,
he complained, was sluggish and persisted in focusing on
extraneous, ex-
tragroup material. I agreed to observe his group and suggested
that first
he obtain some sociometric information by asking each member
privately

to rank-order everyone in the group for general popularity. (I
had hoped
that the discussion of this task would induce the group to turn
its atten-
tion upon itself.) Although we had planned to discuss these
results before
the next group session, unexpected circumstances forced us to
cancel our
presession consultation.
During the next group meeting, the therapist, enthusiastic bur
profes-
sionally inexperienced and insensitive to interpersonal needs,
announced
that he would read aloud the results of the popularity poll.
Hearing this,
the group members grew agitated and fearful. They made it
clear that
they did not wish to know the results. Several members spoke so
vehe-
mently of the devastating possibility that they might appear at
the bottom
of the list that the therapist quickly and permanently abandoned
his plan
of reading the list aloud.
I suggested an alternative plan for the next meeting: each
member
would indicate whose vote he cared about most and then explain
his
choice. This device, also, was too threatening, and only one-
third of the
https://living.33

members ventured a choice. Nevertheless, the group shifted to
an interac-
tional level and developed a degree of tension, involvement, and
exhilara-
tion previously unknown. These men had received the ultimate
message
of rejection from society at large: they were imprisoned,
segregated, and
explicitly labeled as outcasts. To the casual observer, they
seemed hard-
ened, indifferent to the subtleties of interpersonal approval and
disap-
proval. Yet they cared, and cared deeply.
The need for acceptance by and interaction with others is no
different
among people at the opposite pole of human fortunes-those who
occupy
the ultimate realms of power, renown, or wealth. I once worked
with an
enormously wealthy client for three years. The major issues
revolved about
the wedge that money created between herself and others. Did
anyone
value her for herself rather than her money? Was she
continually being ex-
ploited by others? To whom could she complain of the burdens
of a ninety-
million-dollar fortune? The secret of her wealth kept her
isolated from
others. And gifts! How could she possibly give appropriate gifts
without
having others feel either disappointed or awed? There is no
need to belabor

the point; the loneliness of the very privileged is common
knowledge.
(Loneliness is, incidentally, not irrelevant to the group
therapist; in chapter
7, I will discuss the loneliness inherent in the role of group
leader.)
Every group therapist has, I am sure, encountered group
members who
profess indifference to or detachment from the group. They
proclaim, "I
don't care what they say or think or feel about me; they're
nothing to me;
I have no respect for the other members," or words to that
effect. My ex-
perience has been that if I can keep such clients in the group
long enough,
their wishes for contact inevitably surface. They are concerned
at a very
deep level about the group. One member who maintained her
indifferent
posture for many months was once invited to ask the group her
secret
question, the one question she would like most of all to place
before the
group. To everyone's astonishment, this seemingly aloof,
detached woman
posed this question: "How can you put up with me?"
Many clients anticipate meetings with great eagerness or with
anxiety;
some feel too shaken afterward to drive home or to sleep that
night; many
have imaginary conversations with the group during the week.
Moreover,
this engagement with other members is often long-lived; I have

known
many clients who think and dream about the group members
months,
even years, after the group has ended.
In short, people do not feel indifferent toward others in their
group for
long. And clients do not quit the therapy group because of
boredom. Be-
lieve scorn, contempt, fear, discouragement, shame, panic,
hatred! Believe
any of these! But never believe indifference!
In summary, then, I have reviewed some aspects of personality
devel-
opment, mature functioning, psychopathology, and psychiatric
treatment
27 The Correctiue Emotional Experience
from the point of view of interpersonal theory. Many of the
issues that I
have raised have a vital bearing on the therapeutic process in
group ther-
apy: the concept that mental illness emanates from disturbed
interper-
sonal relationships, the role of consensual validation in the
modification
of interpersonal distortions, the definitio n of the therapeutic
process as
an adaptive modification of interpersonal relationships, and the
enduring
nature and potency of the human being's social needs. Let us
now turn to

the corrective emotional experience, the second of the three
concepts nec-
essary to understand the therapeutic factor of interpersonal
learning.
THE CORRECTIVE EMOTIONAL EXPERIENCE
In 1946, Franz Alexander, when describing the mechanism of
psychoana-
lytic cure, introduced the concept of the "corrective emotional
experience."
The basic principle of treatment, he stated, "is to expose the
patient, under
more favorable circumstances, to emotional situations that he
could not
handle in the past. The patient, in order to be helped, must
undergo a cor-
rective emotional experience suitable to repair the traumatic
influence of
previous experience." 34 Alexander insisted that intellectual
insight alone is
insufficient: there must be an emotional component and
systematic reality
testing as well. Patients, while affectively interacting with their
therapist in
a distorted fashion because of transference, gradually must
become aware
of the fact that "these reactions are not appropriate to the
analyst's reac-
tions, not only because he (the analyst) is objective, but also
because he is
what he is, a person in his own right. They are not suited to the
situation be-
tween patient and therapist, and they are equally unsuited to the
patient's
current interpersonal relationships in his daily life."35

Although the idea of the corrective emotional experience was
criticized
over the years because it was misconstrued as contrived,
inauthentic, or
manipulative, contemporary psychotherapies view it as a
cornerstone of
therapeutic effectiveness. Change both at the behavioral level
and at the
deeper level of internalized images of past relationships does
not occur
primarily through interpretation and insight but through
meaningful here-
and-now relational experience that disconfirms the client's
pathogenic be-
liefs.36 When such discomfirmation occurs, change can be
dramatic: clients
express more emotion, recall more personally relevant and
formative expe-
riences, and show evidence of more boldness and a greater
sense of self.37
These basic principles-the importance of the emotional
experience in
therapy and the client's discovery, through reality testing, of the
inappropri-
ateness of his or her interpersonal reactions-are as crucial in
group ther-
apy as in individual therapy, and possibly more so because the
group setting
offers far more opportunities for the generation of corrective
emotional ex-
periences. In the individual setting, the corrective emotional
experience,
https://liefs.36

valuable as it is, may be harder to come by, because the client-
therapist rela-
tionship is more insular and the client is more able to dispute
the spontane-
ity, scope, and authenticity of that relationship. (I believe
Alexander was
aware of that, because at one point he suggested that the analyst
may have
to be an actor, may have to play a role in order to create the
desired emo-
tional atmosphere.) 38
No such simulation is necessary in the therapy group, which
contains
many built-in tensions-tensions whose roots reach deep into
primeval
layers: sibling rivalry, competition for leaders'/parents'
attention, the
struggle for dominance and status, sexual tensions, parataxic
distortions,
and differences in social class, education, and values among the
members.
But the evocation and expression of raw affect is not sufficient:
it has to
be transformed into a corrective emotional experience. For that
to occur
two conditions are required: (1) the members must experience
the group
as sufficiently safe and supportive so that these tensions may be
openly
expressed; (2) there must be sufficient engagement and honest
feedback to

permit effective reality testing.
Over many years of clinical work, I have made it a practice to
interview
clients after they have completed group therapy. I always
inquire about
some critical incident, a turning point, or the most helpful
single event in
therapy. Although "critical incident" is not synonymous with
therapeutic
factor, the two are not unrelated, and much may be learned from
an ex-
amination of single important events. My clients almost
invariably cite an
incident that is highly laden emotionally and involves some
other group
member, rarely the therapist.
The most common type of incident my clients report (as did
clients de-
scribed by Frank and Ascher) 39 involves a sudden expression
of strong dis-
like or anger toward another member. In each instance,
communication
was maintained, the storm was weathered, and the client
experienced a
sense of liberation from inner restraints as well as an enhanced
ability to
explore more deeply his or her interpersonal relationships.
The important characteristics of such critical incidents were:
1. The client expressed strong negative affect.
2. This expression was a unique or novel experience for the
client.
3. The client had always dreaded the expression of anger. Yet

no cata-
strophe ensued: no one left or died; the roof did not collapse.
4. Reality testing ensued. The client realized either that the
anger ex-
pressed was inappropriate in intensity or direction or that prior
avoidance of affect expression had been irrational. The client
may or
may not have gained some insight, that is, learned the reasons
ac-
counting either for the inappropriate affect or for the prior
avoid-
ance of affect experience or expression.
29 The Corrective Emotional Experience
5. The client was enabled to interact more freely and to explore
inter-
personal relationships more deeply.
Thus, when I see two group members in conflict with one
another, I be-
lieve there is an excellent chance that they will be particularly
important
to one another in the course of therapy. In fact, if the conflict is
particu-
larly uncomfortable, I may attempt to ameliorate some of the
discomfort
by expressing that hunch aloud.
The second most common type of critical incident my clients
describe
also involves strong affect-but, in these instances, positive

affect. For ex-
ample, a schizoid client described an incident in which he ran
after and
comforted a distressed group member who had bolted from the
room;
later he spoke of how profoundly he was affected by learning
that he
could care for and help someone else. Others spoke of
discovering their
aliveness or of feeling in touch with themselves. These
incidents had in
common the following characteristics:
1. The client expressed strong positive affect-an unusual
occurrence.
2. The feared catastrophe did not occur-derision, rejection,
engulf-
ment, the destruction of others.
3. The client discovered a previously unknown part of the self
and thus
was enabled to relate to others in a new fashion.
The third most common category of critical incident is similar
to the
second. Clients recall an incident, usually involving self-
disclosure, that
plunged them into greater involvement with the group. For
example, a
previously withdrawn, reticent man who had missed a couple of
meetings
disclosed to the group how desperately he wanted to hear the
group mem-
bers say that they had missed him during his absence. Others,
too, in one

fashion or another, openly asked the group for help.
To summarize, the corrective emotional experience in group
therapy
has several components:
1. A strong expression of emotion, which is interpersonally
directed
and constitutes a risk taken by the client.
2. A group supportive enough to permit this risk taking.
3. Reality testing, which allows the individual to examine the
incident
with the aid of consensual validation from the other members.
4. A recognition of the inappropriateness of certain
interpersonal feel-
ings and behavior or of the inappropriateness of avoiding
certain in-
terpersonal behavior.
5. The ultimate facilitation of the individual's ability to interact
with
others more deeply and honestly.
Therapy is an emotional and a corrective experience. This dual
nature
of the therapeutic process is of elemental significance, and I
will return to
it again and again in this text. We must experience something
strongly;

but we must also, through our faculty of reason, understand the
implica-
tions of that emotional experience.t Over time, the client's
deeply held
beliefs will change-and these changes will be reinforced if the
client's
new interpersonal behaviors evoke constructive interpersonal
responses.
Even subtle interpersonal shifts can reflect a profound change
and need to
be acknowledged and reinforced by the therapist and group
members.
Barbara, a depressed young woman, vividly described her
isolation and
alienation to the group and then turned to Alice, who had been
silent.
Barbara and Alice had often sparred because R1rbarc1 would
llccuse
Alice of ignoring and rejecting her. In this meeting, howeue1;
Barbara
used a more gentle tone and asked Alice about the meaning of
her si-
lence. Alice responded that she was listening carefully and
thinking
about how much they had in common. She then added that
Barbllra's
more gentle inquiry allowed her to give voice to her thoughts
rather
than defend herself against the charge of not caring, a sequence
thllt
had ended badly for them both in earlier sessions. The
seemingly small
but uitally important shift in Barbara's capacity to approach
Alice em-
pathically created an opportunity for repair rather than

repetition.
This formulation has direct relevance to a key concept of group
ther-
apy, the here-and-now, which I will discuss in depth in chapter
6. Here I
will state only chis basic premise: When the therapy group
focuses on the
here-and-now, it increases in power and effectiueness.
But if the here-and-now focus (that is, a focus on what is
happening in
chis room in the immediate present) is to be therapeutic, it must
have t,vo
components: the group members must experience one another
with as
much spontaneity and honesty as possible, and they must also
reflect back
on chat experience. This reflecting back, chis self-reflectiue
loop, is crucial
if an emotional experience is to be transformed into a
therapeutic one. As
we shall see in the discussion of the therapist's tasks in chapter
5, most
groups have little difficulty in entering the emotional stream of
the here-
and-now; but generally it is the therapist's job to keep directing
the group
toward the self-reflective aspect of that process.
The mistaken assumption that a strong emotional experience is
in itself
a sufficient force for change is seductive as well as venerable
..Modern psy-
chotherapy was conceived in chat very error: the first
description of dy-

namic psychotherapy (Freud and Breuer's 1895 Studies on
Hysteria) 40
described a method of cathartic treatment based on the
conviction that
hysteria is caused by a traumatic event to which the individual
has never
31 The Group as Social Microcosm
fully responded emotionally. Since illness was supposed to be
caused by
strangulated affect, treatment was directed toward giving a
voice to the
stillborn emotion. It was not long before Freud recognized the
error: emo-
tional expression, though necessary, is not a sufficient condition
for
change. Freud's discarded ideas have refused to die and have
been the seed
for a continuous fringe of therapeutic ideologies. The Viennese
fin-de-sie-
cle cathartic treatment still lives today in the approaches of
primal
scream, bioenergetics, and the many group leaders who place an
exagger-
ated emphasis on emotional catharsis.
My colleagues and I conducted an intensive investigation of the
process
and outcome of many of the encounter techniques popular in the
1970s
(see chapter 16), and our findings provide much support for the
dual emo-

tional-intellectual components of the psychotherapeutic process.
41
We explored, in a number of ways, the relationship between
each
member's experience in the group and his or her outcome. For
example,
we asked the members after the conclusion of the group to
reflect on
those aspects of the group experience they deemed most
pertinent to
their change. We also asked them during the course of the
group, at the
end of each meeting, to describe which event at that meeting
had the
most personal significance. When we correlated the type of
event with
outcome, we obtained surprising results that disconfirmed many
of the
contemporary stereotypes about the prime ingredients of the
successful
encounter group experience. Although emotional experiences
(expres-
sion and experiencing of strong affect, self-disclosure, giving
and receiv-
ing feedback) were considered extremely important, they did
not
distinguish successful from unsuccessful group members. In
other
words, the members who were unchanged or even had a
destructive ex-
perience were as likely as successful members to value highly
the emo-
tional incidents of the group.
What types of experiences did differentiate the successful from

the
unsuccessful members? There was clear evidence that a
cognitive com-
ponent was essential; some type of cognitive map was needed,
some in-
tellectual system that framed the experience and made sense of
the
emotions evoked in the group. (See chapter 16 for a full
discussion of
this result.) That these findings occurred in groups led by
leaders who
did not attach much importance to the intellectual component
speaks
strongly for its being part of the foundation, not the facade, of
the
change process. 42
THE GROUP AS SOCIAL MICROCOSM
A freely interactive group, with few structural restrictions, will,
in time,
develop into a social microcosm of the participant members.
Given
https://process.42
https://process.41
enough time, group members wiH begin to be themselves: they
will inter-
act with the group members as they interact with others in their
social
sphere, will create in the group the same interpersonal universe
they have

always inhabited. In other words, clients will, over time,
automatically
and inevitably begin to display their maladaptive interpersonal
behavior
in the therapy group. There is no need for them to describe or
give a de-
tailed history of their pathology: they will sooner or later enact
it before
the other group members' eyes. Furthermore, their behavior
serves as ac-
curate data and lacks the unwitting but inevitable blind spots of
self-report.
Character pathology is often hard for the individual to report
because it
is so well assimilated into the fabric of the self and outside of
conscious
and explicit awareness. As a result, group therapy, with its
emphasis on
feedback, is a particularly effective treatment for individuals
with charac-
ter pathology. 43
This concept is of paramount importance in group therapy and is
a
keystone of the entire approach to group therapy. Each
member's inter-
personal style will eventually appear in his or her transactions
in the
group. Some styles result in interpersonal friction that will be
manifest
early in the course of the group. Individuals who are, for
example, angry,
vindictive, harshly judgmental, self-effacing, or grandly
coquettish will
generate considerable interpersonal static even in the first few
meetings.

Their maladaptive social patterns will quickly elicit the group's
attention.
Others may require more time in therapy before their
difficulties manifest
themselves in the here-and-now of the group. This includes
clients who
may be equally or more severely troubled but whose
interpersonal diffi-
culties are more subtle, such as individuals who quietly exploit
others,
those who achieve intimacy to a point but then, becoming
frightened, dis-
engage themselves, or those who pseudo-engage, maintaining a
subordi-
nate, compliant position.
The initial business of a group usually consists of dealing with
the
members whose pathology is most interpersonally blatant. Some
inter-
personal styles become crystal-clear from a single transaction,
some from
a single group meeting, and others require many sessions of
observation
to understand. The development of the ability to identify and
put to ther-
apeutic advantage maladaptive interpersonal behavior as seen in
the so-
cial microcosm of the small group is one of the chief tasks of a
training
program for group psychotherapists. Some clinical examples
may make
these principles more graphic.•·
*In the following clinical examples, as elsewhere in this text, I
have protected clients' privacy by

altering certain facts, such as name, occupation, and age. Also,
the interaction described in the
text is not reproduced verbatim but has been reconstructed from
detailed clinical notes taken
after each therapy meeting.
https://pathology.43
The Grand Dame
Valerie, a twenty-seven-year-old musician, sought therapy with
me pri-
marily because of severe marital discord of several years'
standing. She
had had considerable, unrewarding individual and hypnotic
uncovering
therapy. Her husband, she reported, was an alcoholic who was
reluctant
to engage her socially, intellectually, or sexually. Now the
group could
have, as some groups do, investigated her marriage
interminably. The
members might have taken a complete history of the courtship,
of the
evolution of the discord, of her husband's pathology, of her
reasons for
marrying him, of her role in the conflict. They might have
followed up
this collection of information with advice for changing the
marital inter-
action or perhaps suggestions for a trial or permanent
separation.

But all this historical, problem-solving activity would have been
in
vain: this entire line of inquiry not only disregards the unique
potential of
therapy groups but also is based on the highly questionable
premise that
a client's account of a marriage is even reasonably accurate.
Groups that
function in this manner fail to help the protagonist and also
suffer de-
moralization because of the ineffectiveness of a problem-
solving, histori-
cal group therapy approach. Let us instead observe Valerie's
behavior as it
unfolded in the here-and-now of the group.
Valerie's group behavior was flamboyant. First, there was her
grand en-
trance, always five or ten minutes late. Bedecked in fashionable
but flashy
garb, she would sweep in, sometimes throwing kisses, and
immediately
begin talking, oblivious to whether another member was in the
middle of
a sentence. Here was narcissism in the raw! Her worldview was
so solip-
sistic that it did not take in the possibility that life could have
been going
on in the group before her arrival.
After very few meetings, Valerie began to give gifts: to an
obese female
member, a copy of a new diet book; to a woman with
strabismus, the
name of a good ophthalmologist; to an effeminate gay client, a
subscrip-

tion to Field and Stream magazine (intended, no doubt, to
masculinize
him); to a twenty-four-year-old virginal male, an introduction to
a
promiscuous divorced friend of hers. Gradually it became
apparent that
the gifts were not duty-free. For example, she pried into the
relationship
that developed between the young man and her divorced fri end
and in-
sisted on serving as confidante and go-between, thus exerting
consider-
able control over both individuals.
Her efforts to dominate soon colored all of her interactions in
the
group. I became a challenge to her, and she made various efforts
to control
me. By sheer chance, a few months previously I had seen her
sister in con-
sultation and referred her to a competent therapist, a clinical
psychologist.
In the group Valerie congratulated me for the brilliant tactic of
sending her
sister to a psychologist; I must have divined her deep-seated
aversion to
psychiatrists. Similarly, on another occasion, she responded to a
comment
from me, "How perceptive you were to have noticed my hands
trembling."

The trap was set! In fact, I had neither "divined" her sister's
alleged
aversion to psychiatrists (I had simply referred her to the best
therapist I
knew) nor noted Valerie's trembling hands. If I silently accepted
her un-
deserved tribute, then I would enter into a dishonest collusion
with Va-
lerie; if, on the other hand, I admitted my insensitivity either to
the
trembling of the hands or to the sister's aversion, then, by
acknowledging
my lack of perceptivity, I would have also been bested. She
would control
me either way! In such situations, the therapist has only one
real option:
to change the frame and to comment on the process-the nature
and the
meaning of the entrapment. (I will have a great deal more to say
about rel-
evant therapist technique in chapter 6.)
Valerie vied with me in many other ways. Intuitive and
intellectually
gifted, she became the group expert on dream and fantasy
interpretation.
On one occasion she saw me between group sessions to ask
whether she
could use my name to take a book out of the medical library. On
one
level the request was reasonable: the book (on music therapy)
was related
to her profession; furthermore, having no university affiliation,
she was
not permitted to use the library. However, in the context of the
group

process, the request was complex in that she was testing limits;
granting
her request would have signaled to the group that she had a
special and
unique relationship with me. I clarified these considerations to
her and
suggested further discussion in the next session. Following this
perceived
rebuttal, however, she called the three male members of the
group at
home and, after swearing them to secrecy, arranged to see them.
She en-
gaged in sexual relations with two; the third, a gay man, was
not inter-
ested in her sexual advances but she launched a formidable
seduction
attempt nonetheless.
The following group meeting was horrific. Extraordinarily tense
and
unproductive, it demonstrated the axiom (to be discussed later)
that if
something important in the group is being actively avoided,
then nothing
else of import gets talked about either. Two days later Valerie,
overcome
with anxiety and guilt, asked for an individual session with me
and made
a full confession. It was agreed that the whole matter should be
discussed
in the next group meeting.
Valerie opened the next meeting with the words: "This is
confession
day! Go ahead, Charles!" and then later, "Your turn, Louis,"
deftly manip-

ulating the situation so that the confessed transgressions became
the sole
responsibilities of the men in question, and not herself. Each
man per-
formed as she bade him and, later in the meeting, received from
her a crit-
ical evaluation of his sexual performance. A few weeks later,
Valerie let her
estranged husband know what had happened, and he sent
threatening
messages to all three men. That was the last straw! The
members decided
they could no longer trust her and, in the only such instance I
have known,
voted her out of the group. (She continued her therapy by
joining another
group.) The saga does not end here, but perhaps I have
recounted enough
to illustrate the concept of the group as social microcosm.
Let me summarize. The first step was that Valerie clearly
displayed her
interpersonal pathology in the group. Her narcissism, her need
for adula-
tion, her need to control, her sadistic relationship with men-the
entire
tragic behavioral scroll-unrolled in the here-and-now of
therapy. The
next step was reaction and feedback. The men expressed their
deep hu-
miliation and anger at having to "jump through a hoop" for her

and at re-
ceiving "grades" for their sexual performance. They drew away
from her.
They began to reflect: "I don't want a report card every time I
have sex.
It's controlling, like sleeping with my mother! I'm beginning to
under-
stand more about your husband moving out!" and so on. The
others in
the group, the female members and the therapists, shared the
men's feel-
ings about the wantonly destructive course of Valerie's
behavior-de-
structive for the group as well as for herself.
Most important of all, she had to deal with this fact: she had
joined a
group of troubled individuals who were eager to help each other
and
whom she grew to like and respect; yet, in the course of several
weeks, she
had so poisoned her own environment that, against her
conscious wishes,
she became a pariah, an outcast from a group that could have
been very
helpful to her. Facing and working through these issues in her
subsequent
therapy group enabled her to make substantial personal changes
and to
employ much of her considerable potential constructively in her
later re-
lationships and endeavors.
The Man Who Liked Robin Hood
Ron, a forty-eight-year-old attorney who was separated from his
wife, en-

tered therapy because of depression, anxiety, and intense
feelings of lone-
liness. His relationships with both men and women were highly
problematic. He yearned for a close male friend but had not had
one since
high school. His current relationships with men assumed one of
two
forms: either he and the other man related in a highly
competitive, antag-
onistic fashion, which veered dangerously close to
combativeness, or he
assumed an exceedingly dominant role and soon found the
relationship
empty and dull.
His relationships with women had always followed a predictable
se-
quence: instant attraction, a crescendo of passion, a rapid loss
of interest.
His love for his wife had withered years ago and he was
currently in the
midst of a painful divorce.
Intelligent and highly articulate, Ron immediately assumed a
position
of great influence in the group. He offered a continuous stream
of useful
and thoughtful observations to the other members, yet kept his
own pain
and his own needs well concealed. He requested nothing and
accepted
nothing from me or my co-therapist. In fact, each time I set out

to inter-
act with Ron, I felt myself bracing for battle. His antagonistic
resistance
was so great that for months my major interaction with him
consisted of
repeatedly requesting him to examine his reluctance to
experience me as
someone who could offer help.
"Ron," I suggested, giving it my best shot, "let's understand
what's
happening. You have many areas of unhappiness in your life.
I'm an ex-
perienced therapist, and you come to me for help. You come
regularly, you
never miss a meeting, you pay me for my services, yet you
systematically
prevent me from helping you. Either you so hide your pain that
I find lit-
tle to offer you, or when I do extend some help, you reject it in
one fash-
ion or another. Reason dictates that we should be allies.
Shouldn't we be
working together to help you? Tell me, how does it come about
that we
are adversaries?"
But even that failed to alter our relationship. Ron seemed
bemused and
skillfully and convincingly speculated that I might be
identifying one of
my problems rather than his. His relationship with the other
group mem-
bers was characterized by his insistence on seeing them outside
the group.
He systematically arranged for some extragroup activity with

each of the
members. He was a pilot and took some members flying, others
sailing,
others to lavish dinners; he gave legal advice to some and
became romanti-
cally involved with one of the female members; and (the final
straw) he in-
vited my co-therapist, a female psychiatric resident, for a skiing
weekend.
Furthermore, he refused to examine his behavior or to discuss
these ex-
tragroup meetings in the group, even though the pregroup
preparation
(see chapter 12) had emphasized to all the members that such
unexam-
ined, undiscussed extragroup meetings generally sabotage
therapy.
After one meeting when we pressured him unbearably to
examine the
meaning of the extragroup invitations, especially the skiing
invitation to
my co-therapist, he left the session confused and shaken. On his
way
home, Ron unaccountably began to think of Robin Hood, his
favorite
childhood story but something he had not thought about for
decades.
Following an impulse, he went directly to the children's section
of the
nearest public library to sit in a small child's chair and read the
story one
more time. In a flash, the meaning of his behavior was
illuminated! Why

had the Robin Hood legend always fascinated and delighted
him? Because
Robin Hood rescued people, especially women, from tyrants!
That motif had played a powerful role in his interior life,
beginning
with the Oedipal struggles in his own family. Later, in early
adulthood, he
built up a successful law firm by first assisting in a partnership
and then
enticing his boss's employees to work for him. He had often
been most at-
tracted to women who were attached to some powerful man.
Even his mo-
tives for marrying were blurred: he could not distinguish
between love for
his wife and desire to rescue her from a tyrannical father.
The first stage of interpersonal learning is pathology display.
Ron's
characteristic modes of relating to both men and women
unfolded vividly
in the microcosm of the group. His major interpersonal motif
was to
struggle with and to vanquish other men. He competed openly
and, be-
cause of his intelligence and his great verbal skills, soon
procured the
dominant role in the group. He then began to mobilize the other
members
in the final conspiracy: the unseating of the therapist. He

formed close al-
liances through extragroup meetings and by placing other
members in his
debt by offering favors. Next he endeavored to capture "my
women"-
first the most attractive female member and then my co-
therapist.
Not only was Ron's interpersonal pathology displayed in the
group, but
so were its adverse, self-defeating consequences. His struggles
with men re-
sulted in the undermining of the very reason he had come to
therapy: to ob-
tain help. In fact, the competitive struggle was so powerful that
any help I
extended him was experienced not as help but as defeat, a sign
of weakness.
Furthermore, the microcosm of the group revealed the
consequences
of his actions on the texture of his relationships with his peers.
In time
the other members became aware that Ron did not really relate
to them.
He only appeared to relate but, in actuality, was using them as a
way of
relating to me, the powerful and feared male in the group. The
others
soon felt used, felt the absence of a genuine desire in Ron to
know them,
and gradually began to distance themselves from him. Only
after Ron
was able to understand and to alter his intense and distorted
ways of re-
lating to me was he able to turn to and relate in good faith to

the other
members of the group.
"Those Damn Men"
Linda, forty-six years old and thrice divorced, entered the group
because
of anxiety and severe functional gastrointestinal distress. Her
major in-
terpersonal issue was her tormented, self-destructive
relationship with
her current boyfriend. In fact, throughout her life she had
encountered a
long series of men (father, brothers, bosses, lovers, and
husbands) who
had abused her both physically and psychologically. Her
account of the
abuse that she had suffered, and suffered still, at the hands of
men was
harrowing.
The group could do little to help her, aside from applying balm
to her
wounds and listening empathically to her accounts of continuing
mistreat-
ment by her current boss and boyfriend. Then one day an
unusual incident
occurred that graphically illuminated her dynamics. She called
me one
morning in great distress. She had had an extremely unsettling
altercation

with her boyfriend and felt panicky and suicidal. She felt she
could not
possibly wait for the next group meeting, still four days off, and
pleaded
for an immediate individual session. Although it was greatly
inconvenient,
I rearranged my appointments that afternoon and scheduled time
to meet
her. Approximately thirty minutes before our meeting, she
called and left
word with my secretary that she would not be coming in after
all.
In the next group meeting, when I inquired what had happened,
Linda
said that she had decided to cancel the emergency session
because she was
feeling slightly better by the afternoon, and that she knew I had
a rnle
that I would see a client only one time in an emergency during
the whole
course of group therapy. She therefore thought it might be best
to save
that option for a time when she might be even more in crisis.
I found her response bewildering. I had never made such a rule;
I never
refuse to see someone in real crisis. Nor did any of the other
members of
the group recall my having issued such a dictum. But Linda
stuck to her
guns: she insisted that she had heard me say it, and she was
dissuaded nei-
ther by my denial nor by the unanimous consensus of the other
group
members. Nor did she seem concerned in any way about the

inconve-
nience she had caused me. In the group discussion she grew
defensive and
acnmon10us.
This incident, unfolding in the social microcosm of the group,
was
highly informative and allowed us to obtain an important
perspective on
Linda's responsibility for some of her problematic relationships
with
men. Up until that point, the group had to rely entirely on her
portrayal
of these relationships. Linda's accounts were convincing, and
the group
had come to accept her vision of herself as victim of "all those
damn men
out there." An examination of the here-and-now incident
indicated that
Linda had distorted her perceptions of at least one important
man in her
life: her therapist. Moreover-and this is extremely important-she
had
distorted the incident in a highly predictable fashion: she
experienced me
as far more uncaring, insensitive, and authoritarian than I really
was.
This was new data, and it was convincing data-and it was
displayed
before the eyes of all the members. For the first time, the group
began to
wonder about the accuracy of Linda's accounts of her
relationships with
men. Undoubtedly, she faithfully portrayed her feelings, but it
became ap-

parent that there were perceptual distortions at work: because of
her ex-
pectations of men and her highly conflicted relationships with
them, she
misperceived their actions toward her.
But there was more yet to be learned from the social microcosm.
An
important piece of data was the tone of the discussion: the
defensiveness,
the irritation, the anger. In time I, too, became irritated by the
thankless
inconvenience I had suffered by changing my schedule to meet
with Linda.
I was further irritated by her insistence that I had proclaimed a
certain in-
sensitive rule when I (and the rest of the group) knew I had not.
I fell into
a reverie in which I asked myself, "What would it be like to live
with Linda
all the time instead of an hour and a half a week?" If there were
many
such incidents, I could imagine myself often becoming angry,
exasper-
ated, and uncaring toward her. This is a particularly clear
example of the
concept of the self-fulfilling prophecy described on page 22.
Linda pre-
dicted that men would behave toward her in a certain way and
then, un-
consciously, operated so as to bring this prediction to pass.

Men Who Could Not Feel
Allen, a thirty-year-old unmarried scientist, sought therapy for a
single,
sharply delineated problem: he wanted to be able to feel
sexually stimu-
lated by a woman. Intrigued by this conundrum, the group
searched for
an answer. They investigated his early life, sexual habits, and
fantasies. Fi-
nally, baffled, they turned to other issues in the group. As the
sessions con-
tinued, Allen seemed impassive and insensitive to his own and
others'
pain. On one occasion, for example, an unmarried member in
great dis-
tress announced in sobs that she was pregnant and was planning
to have
an abortion. During her account she also mentioned that she had
had a
bad PCP trip. Allen, seemingly unmoved by her tears, persisted
in posing
intellectual questions about the effects of "angel dust" and was
puzzled
when the group commented on his insensitivity.
So many similar incidents occurred that the group came to
expect no
emotion from him. When directly queried about his feelings, he
re-
sponded as if he had been addressed in Sanskrit or Aramaic.
After some
months the group formulated an answer to his oft-repeated
question,
"Why can't I have sexual feelings toward a woman?" They asked

him to
consider instead why he couldn't have any feelings toward
anybody.
Changes in his behavior occurred very gradually. He learned to
spot
and identify feelings by pursuing telltale autonomic signs:
facial flushing,
gastric tightness, sweating palms. On one occasion a volatile
woman in
the group threatened to leave the group because she was
exasperated try-
ing to relate to "a psychologically deaf and dumb goddamned
robot."
Allen again remained impassive, responding only, "I'm not
going to get
down to your level."
However, the next week when he was asked about the feelings
he had
taken home from the group, he said that after the meeting he
had gone
home and cried like a baby. (When he left the group a year later
and
looked back at the course of his therapy, he identified this
incident as a
critical turning point.) Over the ensuing months he was more
able to feel
and to express his feelings to the other members. His role
within the
group changed from that of tolerated mascot to that of accepted

com-
peer, and his self-esteem rose in accordance with his awareness
of the
members' increased respect for him.
In another group Ed, a forty-seven-year-old engineer, sought
therapy be-
cause of loneliness and his inability to find a suitable mate. Ed's
pattern
of social relationships was barren: he had never had close male
friends
and had only sexualized, unsatisfying, short-lived relationships
with
women who ultimately and invariably rejected him. His good
social skills
and lively sense of humor resulted in his being highly valued by
other
members in the early stages of the group.
As time went on and members deepened their relationships with
one
another, however, Ed was left behind: soon his experience in
the group re-
sembled closely his social life outside the group. The most
obvious aspect
of his behavior was his limited and offensive approach to
women. His
gaze was directed primarily toward their breasts or crotch; his
attention
was voyeuristically directed toward their sexual lives; his
comments to
them were typically simplistic and sexual in nature. Ed
considered the
men in the group unwelcome competitors; for months he did not
initiate
a single transaction with a man.

With so little appreciation for attachments, he, for the most
part, con-
sidered people interchangeable. For example, when a member
described
her obsessive fantasy that her boyfriend, who was often late,
would be
killed in an automobile accident, Ed's response was to assure
her that
she was young, charming, and attractive and would have little
trouble
finding another man of at least equal quality. To take another
example,
Ed was always puzzled when other members appeared troubled
by the
temporary absence of one of the co-therapists or, later, by the
impend-
ing permanent departure of a therapist. Doubtless, he suggested,
there
was, even among the students, a therapist of equal competence.
(In fact,
he had seen in the hall a bosomy psychologist whom he .would
particu-
larly welcome as therapist.)
He put it most succinctly when he described his MDR
(minimum daily
requirement) for affection; in time it became clear to the group
that the
identity of the MDR supplier was incidental to Ed-far less
relevant than
its dependability.
Thus evolved the first phase of the group therapy process: the
display
of interpersonal pathology. Ed did not relate to others so much

a-s he used
them as equipment, as objects to supply his life needs. It was
not long be-
fore he had re-created in the group his habitual-and desolate--
interper-
sonal universe: he was cut off from everyone. Men reciprocated
his total
indifference; women, in general, were disinclined to service his
MDR, and
those women he especially craved were repulsed by his
narrowly sexual-
41 The Social Microcosm: A Dynamic Interaction
ized attentions. The subsequent course of Ed's group therapy
was greatly
informed by his displaying his interpersonal pathology inside
the group,
and his therapy profited enormously from focusing exhaustively
on his re-
lationships with the other group members.
THE SOCIAL MICROCOSM:
A DYNAMIC INTERACTION
There is a rich and subtle dynamic interplay between the group
member
and the group environment. Members shape their own
microcosm, which
in turn pulls characteristic defensive behavior from each. The
more spon-
taneous interaction there is, the more rapid and authentic will be
the de-
velopment of the social microcosm. And that in turn increases

the
likelihood that the central problematic issues of all the members
will be
evoked and addressed.
For example, Nancy, a young woman with borderline
personality dis-
order, entered the group because of a disabling depression, a
subjective
state of disintegration, and a tendency to develop panic when
left alone.
All of Nancy's symptoms had been intensified by the threatened
breakup
of the small commune in which she lived. She had long been
sensitized to
the breakup of nuclear units; as a child she had felt it was her
task to keep
her volatile family together, and now as an adult she nurtured
the fantasy
that when she married, the various factions among her relatives
would be
permanently reconciled.
How were Nancy's dynamics evoked and worked through in the
social
microcosm of the group? Slowly! It took time for these concerns
to man-
ifest themselves. At first, sometimes for weeks on end, Nancy
would work
comfortably on important but minor conflict areas. But then
certain
events in the group would fan her major, smoldering concerns
into anx-
ious conflagration. For example, the absence of a member
would unsettle
her. In fact, much later, in a debriefing interview at the

termination of
therapy, Nancy remarked that she often felt so stunned by the
absence of
any member that she was unable to participate for the entire
session.
Even tardiness troubled her and she would chide members who
were
not punctual. When a member thought about leaving the group,
Nancy
grew deeply concerned and could be counted on to exert
maximal pres-
sure on the member to continue, regardless of the person's best
interests.
When members arranged contacts outside the group meeting,
Nancy be-
came anxious at the threat to the integrity of the group.
Sometimes mem-
bers felt smothered by Nancy. They drew away and expressed
their
objections to her phoning them at home to check on their
absence or late-
ness. Their insistence that she lighten her demands on them
simply ag-
gravated Nancy's anxiety, causing her to increase her protective
efforts.
Although she longed for comfort and safety in the group, it was,
in
fact, the very appearance of these unsettling vicissitudes that
made it pos-
sible for her major conflict areas to become exposed and to

enter the
stream of the therapeutic work.
Not only does the small group provide a social microcosm in
which the
maladaptive behavior of members is clearly displayed, but it
also becomes
a laboratory in which is demonstrated, often with great clarity,
the mean-
ing and the dynamics of the behavior. The therapist sees not
only the be-
havior but also the events triggering it and sometimes, more
important,
the anticipated and real responses of others.
The group interaction is so rich that each member's maladaptive
transac-
tion cycle is repeated many times, and members have multiple
opportunities
for reflection and understanding. But if pathogenic beliefs are
to be altered,
the group members must receive feedback that is clear and
usable. If the
style of feedback delivery is too stressful or provocative,
members may be
unable to process what the other members offer them.
Sometimes the feed-
back may be premature-that is, delivered before sufficient trust
is present
to soften its edge. At other times feedback can be experienced
as devaluing,
coercive, or injurious. 44 How can we avoid unhelpful or
harmful feedback?
Members are less likely to attack and blame one another if they
can look be-
yond surface behavior and become sensitive to one another's

internal expe-
riences and underlying intentions.t Thus empathy is a critical
element in the
successful group. But empathy, particularly with provocative or
aggressive
clients, can be a tall order for group members and therapists
alike. t
The recent contributions of the intersubjective model are
relevant and
helpful here. 45 This model poses members and therapists such
questions as:
"How am I implicated in what I construe as your
provocativeness? What is
my part in it?" In other words, the group members and the
therapist con-
tinuously affect one another. Their relationships, their meaning,
patterns,
and nature, are not fixed or mandated by external influences,
but jointly
constructed. A traditional view of members' behavior sees the
distortion
with which members relate events---either in their past or
within the group
interaction-as solely the creation and responsibility of that
member. An
intersubjective perspective acknowledges the group leader's and
other mem-
bers' contributions to each member's here-and-now experience-
as well as
to the texture of their entire experience in the group.
Consider the client who repeatedly arrives late to the group
meeting.
This is always an irritating event, and group members will
inevitably ex-

press their annoyance. But the therapist should also encourage
the group
to explore the meaning of that particular client's behavior.
Coming late
may mean "I don't really care about the group," but it may also
have
many other, more complex interpersonal meanings: "Nothing
happens
https://injurious.44
43 The Social Microcosm: A Dynamic Interaction
without me, so why should I rush?" or "I bet no one will even
notice my
absence-they don't seem to notice me while I'm there," or
"These rules
are meant for others, not me."
Both the underlying meaning of the individual's behavior and
the im-
pact of that behavior on others need to be revealed and
processed if the
members are to arrive at an empathic understanding of one
another. Em-
pathic capacity is a key component of emotional intelligence46
and facili-
tates transfer of learning from the therapy group to the client's
larger
world. Without a sense of the internal world of others,
relationships are
confusing, frustrating, and repetitive as we mindlessly enlist
others as
players with predetermined roles in our own stories, without
regard to

their actual motivations and aspirations.
Leonard, for example, entered the group with a major problem
of pro-
crastination. In Leonard's view, procrastination was not only a
problem
but also an explanation. It explained his failures, both
professionally and
socially; it explained his discouragement, depression, and
alcoholism.
And yet it was an explanation that obscured meaningful insight
and more
accurate explanations.
In the group we became well acquainted and often irritated or
frus-
trated with Leonard's procrastination. It served as his supreme
mode of
resistance to therapy when all other resistance had failed. When
members
worked hard with Leonard, and when it appeared that part of his
neurotic
character was about to be uprooted, he found ways to delay the
group
work. "I don't want to be upset by the group today," he would
say, or "This
new job is make or break for me"; "I'm just hanging on by my
finger-
nails"; "Give me a break-don't rock the boat"; "I'd been sober
for three
months until the last meeting caused me to stop at the bar on my
way
home." The variations were many, but the theme was consistent.
One day Leonard announced a major development, one for
which he

had long labored: he had quit his job and obtained a position as
a teacher.
Only a single step remained: getting a teaching certificate, a
matter of fill-
ing out an application requiring approximately two hours' labor.
Only two hours and yet he could not do it! He delayed until the
allowed
time had practically expired and, with only one day remaining,
informed
the group about the deadline and lamented the cruelty of his
personal
demon, procrastination. Everyone in the group, including the
therapists,
experienced a strong desire to sit Leonard down, possibly even
in one's
lap, place a pen between his fingers, and guide his hand along
the appli-
cation form. One client, the most mothering member of the
group, did
exactly that: she took him home, fed him, and schoolmarmed
him
through the application form.
As we began to review what had happened, we could now see
his pro-
crastination for what it was: a plaintive, anachronistic plea for a
lost
mother. Many things then fell into place, including the
dynamics behind
Leonard's depressions (which were also desperate pleas for

love), alco-
holism, and compulsive overeating.
The idea of the social microcosm is, I believe, sufficiently
clear: if the
group is conducted such that the members can behave in an
unguarded,
unselfconscious manner, they will, most vividly, re-create and
display
their pathology in the group. Thus in this living drama of the
group meet-
ing, the trained observer has a unique opportunity to understand
the dy-
namics of each client's behavior.
RECOGNITION OF BEHAVIORAL PATTERNS
IN THE SOCIAL MICROCOSM
If therapists are to turn the social microcosm to therapeutic use,
they
must first learn to identify the group members' recurrent
maladaptive in-
terpersonal patterns. In the incident involving Leonard, the
therapist's
vital clue was the emotional response of members and leaders to
Leonard's behavior. These emotional responses are valid and
indispens-
able data: they should not be overlooked or underestimated. The
therapist
or other group members may feel angry toward a member, or
exploited,
or sucked dry, or steamrollered, or intimidated, or bored, or
tearful, or
any of the infinite number of ways one person can feel toward
another.

These feelings represent data-a bit of the truth about the other
per-
son-and should be taken seriously by the therapist. If the
feelings
elicited in others are highly discordant with the feelings that the
client
would like to engender in others, or if the feelings aroused are
desired, yet
inhibit growth (as in the case of Leonard), then therein lies a
crucial part
of the client's problem. Of course there are many complications
inherent
in this thesis. Some critics might say that a strong emotional
response is
often due to pathology not of the subject but of the respondent.
If, for ex-
ample, a self-confident, assertive man evokes strong feelings of
fear, in-
tense envy, or bitter resentment in another man, we can hardly
conclude
that the response is reflective of the farmer's pathology. There
is a distinct
advantage in the therapy group format: because the group
contains multi-
ple observers, it is easier to differentiate idiosyncratic a nd
highly subjec-
tive responses from more objective ones.
The emotional response of any single member is not sufficient;
thera-
pists need confirmatory evidence. They look for repetitive
patterns over
time and for multiple responses-that is, the reactions of several
other
members (referred to as consensual validation) to the
individual. Ulti-

mately therapists rely on the most valuable evidence of all: their
own
emotional responses. Therapists must be able to attend to their
own reac-
45 Recognition of Behavioral Patterns in the Social Microcosm
tions to the client, an essential skill in all relational models. If,
as Kiesler
states, we are "hooked" by the interpersonal behavior of a
member, our
own reactions are our best interpersonal informatio n about the
client's
impact on others. 47
Therapeutic value follows, however, only if we are able to get
"un-
hooked"-that is, to resist engaging in the usual behavior the
client elicits
from others, which only reinforces the usual interpersonal
cycles. This
process of retaining or regaining our objectivity provides us
with mean-
ingful feedback about the interpersonal transaction. From this
perspec-
tive, the thoughts, fantasies, and actual behavior elicited in the
therapist
by each group member should be treated as gold. Our reactions
are in-
valuable data, not failings. It is impossible not to get hooked by
our
clients, except by staying so far removed from the client's
experience that
we are untouched by it-an impersonal distance that reduces our

thera-
peutic effectiveness.
A critic might ask, "How can we be certain that therapists'
reactions
are 'objective'?" Co-therapy provides one answer to that
question. Co-
therapists are exposed together to the same clinical situation.
Comparing
their reactions permits a clearer discrimination between their
own subjec-
tive responses and objective assessments of the interactions.
Furthermore,
group therapists may have a calm and privileged vantage point,
since, un-
like individual therapists, they witness countless compelling
maladaptive
interpersonal dramas unfold without themselves being at the
center of all
these interactions.
Still, therapists do have their blind spots, their own areas of
interper-
sonal conflict and distortion. How can we be certain these are
not cloud-
ing their observations in the course of group therapy? I will
address this
issue fully in later chapters on training and on the therapist's
tasks and
techniques, but for now note only that this argument is a
powerful reason
for therapists to know themselves as fully as possible. Thus it is
incumbent
upon the neophyte group therapist to embark on a lifelong
journey of self-
exploration, a journey that includes both individual and group

therapy.
None of this is meant to imply that therapists should not take
seriously
the responses and feedback of all clients, including those who
are highly
disturbed. Even the most exaggerated, irrational responses
contain a core
of reality. Furthermore, the disturbed client may be a valuable,
accurate
source of feedback at other times: no individual is highly
conflicted in
every area. And, of course, an idiosyncratic response may
contain much
information about the respondent.
This final point constitutes a basic axiom for the group
therapist.
Not infrequently, members of a group respond very differently
to the
same stimulus. An incident may occur in the group that each of
seven or
eight members perceives, observes, and interprets differently.
One com-
mon stimulus and eight different responses-how can that be?
There
seems to be only one plausible explanation: there are eight
different
inner worlds. Splendid! After all, the aim of therapy is to help
clients
understand and alter their inner worlds. Thus, analysis of these

differ-
ing responses is a royal road-a via regia-into the inner world of
the
group member.
For example, consider the first illustration offered in this
chapter, the
group containing Valerie, a flamboyant, controlling member. In
accord
with their inner world, each of the group members responded
very differ-
ently to her, ranging from obsequious acquiescence to lust and
gratitude
to impotent fury or effective confrontation.
Or, again, consider certain structural aspects of the group
meeting:
members have markedly different responses to sharing the
group's or the
therapist's attention, to disclosing themselves, to asking for help
or help-
ing others. Nowhere are such differences more apparent than in
the trans-
ference-the members' responses to the leader: the same therapist
will be
experienced by different members as warm, cold, rejecting,
accepting,
competent, or bumbling. This range of perspectives can be
humbling and
even overwhelming for therapists, particularly neophytes.
THE SOCIAL MICROCOSM-IS IT REAL?
I have often heard group members challenge the veracity of the
social mi-
crocosm. Members may claim that their behavior in this

particular group
is atypical, not at all representative of their normal behavior. Or
that this
is a group of troubled individuals who have difficulty
perceiving them ac-
curately. Or even that group therapy is not real; it is an
artificial, contrived
experience that distorts rather than reflects one's real behavior.
To the
neophyte therapist, these arguments may seem formidable, even
persua-
sive, but they are in fact truth-distorting. In one sense, the
group is artifi-
cial: members do not choose their friends from the group; they
are not
central to one another; they do not live, work, or eat together;
although
they relate in a personal manner, their entire relationship
consists of
meetings in a professional's office once or twice a week; and
the relation-
ships are transient-the end of the relationship is built into the
social con-
tract at the very beginning.
When faced with these arguments, I often think of Earl and
Mar-
guerite, members in a group I led long ago. Earl had been in the
group for
four months when Marguerite was introduced. They both
blushed to see
the other, because, by chance, only a month earlier, they had
gone on a
Sierra Club camping trip together for a night and been
"intimate." Nei-

47 Oueruiew
ther wanted to be in the group with the other. To Earl,
Marguerite was a
foolish, empty girl, "a mindless piece of ass," as he was to put it
later in
the group. To Marguerite, Earl was a dull nonentity, whose
penis she had
made use of as a means of retaliation against her husband.
They worked together in the group once a week for about a
year. Dur-
ing that time, they came to know each other intimately in a
fuller sense of
the word: they shared their deepest feelings; they weathered
fierce, vicious
battles; they helped each other through suicidal depressions;
and, on more
than one occasion, they wept for each other. Which was the real
world
and which the artificial?
One group member stated, "For the longest time I believed the
group
was a natural place for unnatural experiences. It was only later
that I re-
alized the opposite-it is an unnatural place for natural
experiences." 48
One of the things that makes the therapy group real is that it
eliminates
social, sexual, and status games; members go through vital life
experi-
ences together, they shed reality-distorting facades and strive to

be honest
with one another. How many times have I heard a group member
say,
"This is the first time I have ever told this to anyone"? The
group mem-
bers are not strangers. Quite the contrary: they know one
another deeply
and fully. Yes, it is true that members spend only a small
fraction of their
lives together. But psychological reality is not equivalent to
physical real-
ity. Psychologically, group members spend infinitely more time
together
than the one or two meetings a week when they physically
occupy the
same office.
OVERVIEW
Let us now return to the primary task of this chapter: to define
and de-
scribe the therapeutic factor of interpersonal learning. All the
necessary
premises have been posited and described in this discussion of:
1. The importance of interpersonal relationships
2. The corrective emotional experience
3. The group as a social microcosm
I have discussed these components separately. Now, if we
recombine
them into a logical sequence, the mechanism of interpersonal
learning as
a therapeutic factor becomes evident:
I. Psychological symptomatology emanates from disturbed

interpersonal
relationships. The task of psychotherapy is to help the client
learn how
to develop distortion-free, gratifying interpersonal
relationships.
II. The psychotherapy group, provided its development is
unhampered
by severe structural restrictions, evolves into a social
microcosm, a
miniaturized representation of each member's social universe.
III. The group members, through feedback from others, self-
reflection,
and self-observation, become aware of significant aspects of
their in-
terpersonal behavior: their strengths, their limitations, their
inter-
personal distortions, and the maladaptive behavior that elicits
unwanted responses from other people. The client, who will
often
have had a series of disastrous relationships and subsequently
suf-
fered rejection, has failed to learn from these experiences
because
others, sensing the person's general insecurity and abiding by
the
rules of etiquette governing normal social interaction, have not
com-
municated the reasons for rejection. Therefore, and this is
impor-
tant, clients have never learned to discriminate between

objectionable aspects of their behavior and a self-concept as a
to-
tally unacceptable person. The therapy group, with its
encourage-
ment of accurate feedback, makes such discrimination possible.
IV. In the therapy group, a regular interpersonal sequence
occurs:
A. Pathology display: the member displays his or her behavior.
B. Through feedback and self-observation, clients
1. become better witnesses of their own behavior;
2. appreciate the impact of that behavior on
a. the feelings of others;
b. the opinions that others have of them;
c. the opinions they have of themselves.
V. The client who has become fully aware of this sequence also
be-
comes aware of personal responsibility for it: each individual is
the
author of his or her own interpersonal world.
VI. Individuals who fully accept personal responsibility for the
shaping
of their interpersonal world may then begin to grapple with the
corollary of this discovery: if they created their social -relational
world, then they have the power to change it.
VII. The depth and meaningfulness of these understandings are
directly
proportional to the amount of affect associated with the
sequence.
The more real and the more emotional an experience, the more
po-

tent is its impact; the more distant and intellectualized the
experi-
ence, the less effective is the learning.
VIII. As a result of this group therapy sequence, the client
gradually
changes by risking new ways of being with others. The
likelihood
that change will occur is a function of
A. The client's motivation for change and the amount of
personal
discomfort and dissatisfaction with current modes of behavior;
49 Transference and Insight
B. The client's involvement in the group-that is, how much the
client allows the group to matter;
C. The rigidity of the client's character structure and
interpersonal
style.
IX. Once change, even modest change, occurs, the client
appreciates that
some feared calamity, which had hitherto prevented such
behavior,
has been irrational and can be disconfirmed; the change in
behavior
has not resulted in such calamities as death, destruction,
abandon-
ment, derision, or engulfment.
X. The social microcosm concept is bidirectional: not only does

outside
behavior become manifest in the group, but behavior learned in
the
group is eventually carried over into the client's social
environment,
and alterations appear in clients' interpersonal behavior outside
the
group.
XI. Gradually an adaptive spiral is set in motion, at first inside
and then
outside the group. As a client's interpersonal distorti ons
diminish,
his or her ability to form rewarding relationships is enhanced.
Social
anxiety decreases; self-esteem rises; the need for self-
concealment di-
minishes. Behavior change is an essential component of
effective
group therapy, as even small changes elicit positive responses
from
others, who show more approval and acceptance of the client,
which
further increases self-esteem and encourages further change. 49
Even-
tually the adaptive spiral achieves such autonomy and efficacy
that
professional therapy is no longer necessary.
Each of the steps of this sequence requires different and
specific facili-
tation by the therapist. At various points, for example, the
therapist must
offer specific feedback, encourage self-observation, clarify the
concept of
responsibility, exhort the client into risk taking, disconfirm

fantasized
calamitous consequences, reinforce the transfer of learning, and
so on.
Each of these tasks and techniques will be fully discussed in
chapters 5
and 6.
TRANSFERENCE AND INSIGHT
Before concluding the examination of interpersonal learning as
a media-
tor of change, I wish to call attention to two concepts that
deserve further
discussion. Transference and insight play too central a role in
most for-
mulations of the therapeutic process to be passed over lightly. I
rely heav-
ily on both of these concepts in my therapeutic work and do not
mean to
slight them. What I have done in this chapter is to embed them
both into
the factor of interpersonal learning.
https://change.49
Transference is a specific form of interpersonal perceptual
distortion.
In individual psychotherapy, the recognition and the working
through of
this distortion is of paramount importance. In group therapy,
working
through interpersonal distortions is, as we have seen, of no less
impor-

tance; however, the range and variety of distortions are
considerably
greater. Working through the transference-that is, the distortion
in the
relationship to the therapist-now becomes only one of a series
of dis-
tortions to be examined in the therapy process.
For many clients, perhaps for the majority, it is the most
important re-
lationship to work through, because the therapist is the
personification of
parental images, of teachers, of authority, of established
tradition, of in-
corporated values. But most clients are also conflicted in other
interper-
sonal domains: for example, power, assertiveness, anger,
competitiveness
with peers, intimacy, sexuality, generosity, greed, envy.
Considerable research emphasizes the importance many group
mem-
bers place on working through relationships with other members
rather
than with the leader. 50 To take one example, a team of
researchers asked
members, in a twelve-month follow-up of a short-term crisis
group, to in-
dicate the source of the help each had received. Forty-two
percent felt that
the group members and not the therapist had been helpful, and
28 percent
responded that both had been helpful. Only 5 percent said that
the thera-
pist alone was a major contributor to change. 51

This body of research has important implications for the
technique of
the group therapist: rather than focusing exclusively on the
client-therapist
relationship, therapists must facilitate the development and
working-
through of interactions among members. I will have much more
to say
about these issues in chapters 6 and 7.
Insight defies precise description; it is not a unitary concept. I
prefer to
employ it in the general sense of "sighting inward"-a process
encom-
passing clarification, explanation, and derepression. Insight
occurs when
one discovers something important about oneself-about one's
behavior,
one's motivational system, or one's unconscious.
In the group therapy process, clients may obtain insight on at
least four
different levels:
1. Clients may gain a more objective perspective on their
interpersonal
presentation. They may for the first time learn how they are
seen by other
people: as tense, warm, aloof, seductive, bitter, arrogant,
pompous, obse-
quious, and so on.
2. Clients may gain some understanding into their more complex
interac-
tional patterns of behavior. Any of a vast number of patterns
may become

clear to them: for example, that they exploit others, court
constant admira-
tion, seduce and then reject or withdraw, compete relentlessly,
plead for love,
or relate only to the therapist or either the male or female
members.
https://change.51
https://leader.50
51 Transference and Insight
3. The third level may be termed motivational insight. Clients
may learn
why they do what they do to and with other people. A common
form this
type of insight assumes is learning that one behaves in certain
ways be-
cause of the belief that different behavior would bring about
some cata-
strophe: one might be humiliated, scorned, destroyed, or
abandoned.
Aloof, detached clients, for example, may understand that they
shun close-
ness because of fears of being engulfed and losing themselves;
competitive,
vindictive, controlling clients may understand that they are
frightened of
their deep, insatiable cravings for nurturance; timid, obsequious
individu-
als may dread the eruption of their repressed, destructive rage.
4. A fourth level of insight, genetic insight, attempts to hel p
clients un-
derstand how they got to be the way they are. Through an

exploration of
the impact of early family and environmental experiences, the
client un-
derstands the genesis of current patterns of behavior. The
theoretical
framework and the language in which the genetic explanation is
couched
are, of course, largely dependent on the therapist's school of
conviction.
I have listed these four levels in the order of degree of
inference. An
unfortunate and long-standing conceptual error has resulted, in
part,
from the tendency to equate a "superficial-deep" sequence with
this "de-
gree of inference" sequence. Furthermore, "deep" has become
equated
with "profound" or "good," and superficial with "trivial,"
"obvious," or
"inconsequential." Psychoanalysts have, in the past,
disseminated the be-
fief that the more profound the therapist, the deeper the
interpretation
(from the perspective of early life events) and thus the more
complete the
treatment. There is, however, not a single shred of evidence to
support
this conclusion.
Every therapist has encountered clients who have achieved
considerable
genetic insight based on some accepted theory of child
development or
psychopathology-be it that of Freud, Klein, Winnicott,
Kernberg, or

Kohut-and yet made no therapeutic progress. On the other hand,
it is
commonplace for significant clinical change to occur in the
absence of ge-
netic insight. Nor is there a demonstrated relationship between
the acqui-
sition of genetic insight and the persistence of change. In fact,
there is
much reason to question the validity of our most revered
assumptions
about the relationship between types of early experience and
adult behav-
ior and character structure. 52
For one thing, we must take into account recent neurobiological
re-
search into the storage of memory. Memory is currently
understood to
consist of at least two forms, with two distinct brain pathways.
53 We are
most familiar with the form of memory known as "explicit
memory." This
memory consists of recalled details, events, and the
autobiographical rec-
ollections of one's life, and it has historically been the focus of
exploration
and interpretation in the psychodynamic therapies. A second
form of
https://pathways.53
memory, "implicit memory," houses our earliest relational
experiences,

many of which precede our use of language or symbols. This
memory
(also referred to as "procedural memory") shapes our beliefs
about how to
proceed in our relational world. Unlike explicit memory,
implicit memory
is not fully reached through the usual psychotherapeutic
dialogue but, in-
stead, through the relational and emotional component of
therapy.
Psychoanalytic theory is changing as a result of this new
understanding
of memory. Fonagy, a prominent analytic theorist and
researcher, con-
ducted an exhaustive review of the psychoanalytic process and
outcome
literature. His conclusion: "The recovery of past experience may
be help-
ful, but the understanding of current ways of being with the
other is the
key to change. For this, both self and other representations may
need to
alter and this can only be done effectively in the here and now.
"54 In other
words, the actual moment-to-moment experience of the client
and thera-
pist in the therapy relationship is the engine of change.
A fuller discussion of causality would take us too far afield
from inter-
personal learning, but I will return to the issue in chapters 5 and
6. For
now, it is sufficient to emphasize that there is little doubt that
intellectual
understanding lubricates the machinery of change. It is

important that in-
sight-"sighting in"---occur, but in its generic, not its genetic,
sense. And
psychotherapists need to disengage the concept of "profound" or
"signif-
icant" intellectual understanding from temporal considerations.
Some-
thing that is deeply felt or has deep meaning for a client may or -
as is
usually the case---may not be related to the unraveling of the
early gene-
sis of behavior.
Chapter 1
THE THERAPEUTIC
FACTORS
D oes group therapy help clients? Indeed it does. A persuasive
body of outcome research has demonstrated unequivocally that
group ther-
apy is a highly effective form of psychotherapy and that it is at
least equal
to individual psychotherapy in its power to provide meaningful
benefit. 1
How does group therapy help clients? A naive question,
perhaps. But if
we can answer it with some measure of precision and certainty,
we will
have at our disposal a central organizing principle w ith which to
ap-

proach the most vexing and controversial problems of
psychotherapy.
Once identified, the crucial aspects of the process of change
will consti-
tute a rational basis for the therapist's selection of tactics and
strategies to
shape the group experience to maximize its potency with
different clients
and in different settings.
I suggest that therapeutic change is an enormously complex
process
that occurs through an intricate interplay of human experiences,
which I
will refer to as "therapeutic factors." There is considerable
advantage in
approaching the complex through the simple, the total
phenomenon
through its basic component processes. Accordingly, I begin by
describing
and discussing these elemental factors.
From my perspective, natural lines of cleavage divide the
therapeutic
experience into eleven primary factors:
1. Instillation of hope
2. Universality
3. Imparting information
4. Altruism
5. The corrective recapitulation of the primary family group
6. Development of socializing techniques
2 THE THERAPEUTIC FACTORS

7. Imitative behavior
8. Interpersonal learning
9. Group cohesiveness
10. Catharsis
11. Existential factors
In the rest of this chapter, I discuss the first seven factors. I
consider in-
terpersonal learning and group cohesiveness so important and
complex
that I have treated them separately, in the next two chapters.
Existential
factors are discussed in chapter 4, where they are best
understood in the
context of other material presented there. Catharsis is
intricately interwo-
ven with other therapeutic factors and will also be discussed in
chapter 4.
The distinctions among these factors are arbitrary. Although I
discuss
them singly, they are interdependent and neither occur nor
function sepa-
rately. Moreover, these factors may represent different parts of
the change
process: some factors (for example, interpersonal learning) act
at the level
of cognition; some (for example, development of socializing
techniques)
act at the level of behavioral change; some (for example,
catharsis) act at
the level of emotion; and some (for example, cohesiveness) may
be more
accurately described as preconditions for change. t Although the

same
therapeutic factors operate in every type of therapy group, their
interplay
and differential importance can vary widely from group to
group. Fur-
thermore, because of individual differences, participants in the
same
group benefit from widely different clusters of therapeutic
factors. t
Keeping in mind that the therapeutic factors are arbitrary
constructs,
we can view them as providing a cognitive map for the student-
reader.
This grouping of the therapeutic factors is not set in concrete;
other clin-
icians and researchers have arrived at a different, and also
arbitrary, clus-
ter of factors. 2 No explanatory system can encompass all of
therapy. At
its core, the therapy process is infinitely complex, and there is
no end to
the number of pathways through the experience. (I will discuss
all of
these issues more fully in chapter 4.)
The inventory of therapeutic factors I propose issues from my
clinical
experience, from the experience of other therapists, from the
views of the
successfully treated group patient, and from relevant systematic
research.
None of these sources is beyond doubt, however; neither group
members
nor group leaders are entirely objective, and our research
methodology is

often crude and inapplicable.
From the group therapists we obtain a variegated and internally
incon-
sistent inventory of therapeutic factors (see chapter 4).
Therapists, by no
means disinterested or unbiased observers, have invested
considerable
time and energy in mastering a certain therapeutic approach.
Their an-
swers will be determined largely by their particular school of
conviction.
3 The Therapeutic Factors
Even among therapists who share the same ideology and speak
the same
language, there may be no consensus about the reasons clients
improve. In
research on encounter groups, my colleagues and I learned that
many suc-
cessful group leaders attributed their success to factors that
were irrele-
vant to the therapy process: for example, the hot-seat technique,
or
nonverbal exercises, or the direct impact of a therapist's own
person (see
chapter 16).3 But that does not surprise us. The history of
psychotherapy
abounds in healers who were effective, but not for the reasons
they sup-
posed. At other times we therapists throw up our hands in
bewilderment.
Who has not had a client who made vast improvement for

entirely obscure
reasons?
Group members at the end of a course of group therapy can
supply
data about the therapeutic factors they considered most and
least helpful.
Yet we know that such evaluations will be incomplete and their
accuracy
limited. Will the group members not, perhaps, focus primarily
on superfi-
cial factors and neglect some profound healing forces that may
be beyond
their awareness? Will their responses not be influenced by a
variety of fac-
tors difficult to control? It is entirely possible, for example, that
their
views may be distorted by the nature of their relationship to the
therapist
or to the group. (One team of researchers demonstrated that
when pa-
tients were interviewed four years after the conclusion of
therapy, they
were far more apt to comment on unhelpful or harmful aspects
of their
group experience than when interviewed immediately at its
conclusion.) 4
Research has also shown, for example, that the therapeutic
factors valued
by group members may differ greatly from those cited by their
therapists
or by group observers, 5 an observation also made in individual
psy-
chotherapy. Furthermore, many confounding factors influence
the client's

evaluation of the therapeutic factors: for example, the length of
time in
treatment and the level of a client's functioning, 6 the type of
group (that
is, whether outpatient, inpatient, day hospital, brief therapy),7
the age
and the diagnosis of a client, 8 and the ideology of the group
leader. 9 An-
other factor that complicates the search for common therapeutic
factors
is the extent to which different group members perceive and
experience
the same event in different ways.t Any given experience may be
important
or helpful to some and inconsequential or even harmful to
others.
Despite these limitations, clients' reports are a rich and
relatively un-
tapped source of information. After all, it is their experience,
theirs alone,
and the farther we move from the clients' experience, the more
inferential
are our conclusions. To be sure, there are aspects of the process
of change
that operate outside a client's awareness, but it does not follow
that we
should disregard what clients do say.
There is an art to obtaining clients' reports. Paper-and-pencil or
sort-
ing questionnaires provide easy data but often miss the nuances
and the

richness of the clients' experience. The more the questioner can
enter into
the experiential world of the client, the more lucid and
meaningful the re-
port of the therapy experience becomes. To the degree that the
therapist
is able to suppress personal bias and avoid influencing the
client's re-
sponses, he or she becomes the ideal questioner: the therapist is
trusted
and understands more than anyone else the inner world of the
client.
In addition to therapists' views and clients' reports, there is a
third im-
portant method of evaluating the therapeutic factors: the
systematic re-
search approach. The most common research strategy by far is
to correlate
in-therapy variables with outcome in therapy. By discovering
which vari-
ables are significantly related to successful outcomes, one can
establish a
reasonable base from which to begin to delineate the therapeutic
factors.
However, there are many inherent problems in this approach:
the measure-
ment of outcome is itself a methodological morass, and the
selection and
measurement of the in-therapy variables are equally
problematic. ~- 10
I have drawn from all these methods to derive the therapeutic
factors

discussed in this book. Still, I do not consider these conclusions
definitive;
rather, I offer them as provisional guidelines that may be tested
and deep-
ened by other clinical researchers. For my part, I am satisfied
that they de-
rive from the best available evidence at this time and that they
constitute
the basis of an effective approach to therapy.
INSTILLATION OF HOPE
The instillation and maintenance of hope is crucial in any
psychother-
apy. Not only is hope required to keep the client in therapy so
that other
therapeutic factors may take effect, but faith in a treatment
mode can in
itself be therapeutically effective. Several studies have
demonstrated that
a high expectation of help before the start of therapy is
significantly
correlated with a positive therapy outcome. 11 Consider also the
massive
data documenting the efficacy of faith healing and placebo
treatment-
therapies mediated entirely through hope and conviction. A
positive
outcome in psychotherapy is more likely when the client and the
thera-
pist have similar expectations of the treatment. 12 The power of
expecta-
tions extends beyond imagination alone. Recent brain imaging
studies
demonstrate that the placebo is not inactive but can have a
direct physi-

ological effect on the brain. 13
~we are better able to evaluate therapy outcome in general than
we are able to measure the re-
lationships between these process variables and outcomes.
Kivlighan and colleagues have devel-
oped a promising scale, the Group Helpful Impacts Scale, that
tries to capture the entirety of
the group therapeutic process in a multidimensional fashion that
encompasses therapy tasks
and therapy relationships as well as group process, client, and
leader variables.
https://brain.13
https://treatment.12
https://outcome.11
5 Instillation of Hope
Group therapists can capitalize on this factor by doing whatever
we can
to increase clients' belief and confidence in the efficacy of the
group
mode. This task begins before the group starts, in the pregroup
orienta-
tion, in which the therapist reinforces positive expectations,
corrects neg-
ative preconceptions, and presents a lucid and powerful
explanation of
the group's healing properties. (See chapter 10 for a full
discussion of the
pregroup preparation procedure.)
Group therapy not only draws from the general ameliorative
effects of

positive expectations but also benefits from a source of hope
that is
unique to the group format. Therapy groups invariably contain
individu-
als who are at different points along a coping-collapse
continuum. Each
member thus has considerable contact with others-often
individuals
with similar problems-who have improved as a result of therapy.
I have
often heard clients remark at the end of their group therapy how
impor-
tant it was for them to have observed the improvement of
others. Re-
markably, hope can be a powerful force even in groups of
individuals
combating advanced cancer who lose cherished group members
to the dis-
ease. Hope is flexible--it redefines itself to fit the immediate
parameters,
becoming hope for comfort, for dignity, for connection with
others, or for
minimum physical discomfort.14
Group therapists should by no means be above exploiting this
factor by
periodically calling attention to the improvement that members
have
made. If I happen to receive notes from recently terminated
members in-
forming me of their continued improvement, I make a point of
sharing
this with the current group. Senior group members often assume
this
function by offering spontaneous testimonials to new, skeptical
members.

Research has shown that it is also vitally important that
therapists be-
lieve in themselves and in the efficacy of their group. 15 I
sincerely believe
that I am able to help every motivated client who is willing to
work in the
group for at least six months. In my initial meetings with clients
individ-
ually, I share this conviction with them and attempt to imbue
them with
my optimism.
Many of the self-help groups-for example, Compassionate
Friends
(for bereaved parents), Men Overcoming Violence (men who
batter), Sur-
vivors of Incest, and Mended Heart (heart surgery patients) -
place heavy
emphasis on the instillation of hope. 16 A major part of
Recovery, Inc. (for
current and former psychiatric patients) and Alcoholics
Anonymous meet-
ings is dedicated to testimonials. At each meeting, members of
Recovery,
Inc. give accounts of potentially stressful incidents in which
they avoided
tension by the application of Recovery, Inc. methods, and
successful Alco-
holics Anonymous members tell their stories of downfall and
then rescue
by AA. One of the great strengths of Alcoholics Anonymous is
the fact
that the leaders are all alcoholics-living inspirations to the
others.

https://group.15
https://discomfort.14
Substance abuse treatment programs commonly mobilize hope
in par-
ticipants by using recovered drug addicts as group leaders.
Members are
inspired and expectations raised by contact with those who have
trod the
same path and found the way back. A similar approach is used
for indi-
viduals with chronic medical illnesses such as arthritis and
heart disease.
These self-management groups use trained peers to encourage
members
to cope actively with their medical conditions.17 The
inspiration provided
to participants by their peers results in substantial
improvements in med-
ical outcomes, reduces health care costs, promotes the
individual's sense
of self-efficacy, and often makes group interventions superior to
individ-
ual therapies. 18
UNIVERSALITY
Many individuals enter therapy with the disquieting thought that
they are
unique in their wretchedness, that they alone have certain
frightening or
unacceptable problems, thoughts, impulses, and fantasies. Of
course,

there is a core of truth to this notion, since most clients have
had an un-
usual constellation of severe life stresses and are periodically
flooded by
frightening material that has leaked from their unconscious.
To some extent this is true for all of us, but many clients,
because of
their extreme social isolation, have a heightened sense of
uniqueness.
Their interpersonal difficulties preclude the possibility of deep
intimacy.
In everyday life they neither learn about others' analogous
feelings and ex-
periences nor avail themselves of the opportunity to confide in,
and ulti-
mately to be validated and accepted by, others.
In the therapy group, especially in the early stages, the
disconfirmation
of a client's feelings of uniqueness is a powerful source of
relief. After
hearing other members disclose concerns similar to their own,
clients re-
port feeling more in touch with the world and describe the
process as a
"welcome to the human race" experience. Simply put, the
phenomenon
finds expression in the cliche "We're all in the same boat"-or
perhaps
more cynically, "Misery loves company."
There is no human deed or thought that lies fully outside the
experi-
ence of other people. I have heard group members reveal such
acts as in-

cest, torture, burglary, embezzlement, murder, attempted
suicide, and
fantasies of an even more desperate nature. Invariably, I have
observed
other group members reach out and embrace these very acts as
within the
realm of their own possibilities, often following through the
door of dis-
closure opened by one group member's trust or courage. Long
ago Freud
noted that the staunchest taboos (against incest and patricide)
were con-
structed precisely because these very impulses are part of the
human
being's deepest nature.
https://therapies.18
https://conditions.17
7 Universality
Nor is this form of aid limited to group therapy. Universality
plays a
role in individual therapy also, although in that format there is
less op-
portunity for consensual validation, as therapists choose to
restrict their
degree of personal transparency.
During my own 600-hour analysis I had a striking personal
encounter
with the therapeutic factor of universality. It happened when I
was in the
midst of describing my extremely ambivalent feelings toward
my mother.

I was very much troubled by the fact that, despite my strong
positive sen-
timents, I was also beset with death wishes for her, as I stood to
inherit
part of her estate. My analyst responded simply, "That seems to
be the
way we're built." That artless statement not only offered me
considerable
relief but enabled me to explore my ambivalence in great depth.
Despite the complexity of human problems, certain common
denomi-
nators between individuals are clearly evident, and the members
of a ther-
apy group soon perceive their similarities to one another. An
example is
illustrative: For many years I asked members of T-groups (these
are non-
clients-primarily medical students, psychiatric residents, nurses,
psychi-
atric technicians, and Peace Corps volunteers; see chapter 16) to
engage in
a "top-secret" task in which they were asked to write,
anonymously, on a
slip of paper the one thing they would be most disinclined to
share with
the group. The secrets prove to be startlingly similar, with a
couple of
major themes predominating. The most common secret is a deep
convic-
tion of basic inadequacy-a feeling that one is basically
incompetent,
that one bluffs one's way through life. Next in frequency is a
deep sense of
interpersonal alienation-that, despite appearances, one really
does not,

or cannot, care for or love another person. The third most
frequent cate-
gory is some variety of sexual secret. These chief concerns of
nonclients
are qualitatively the same in individuals seeking professional
help. Almost
invariably, our clients experience deep concern about their
sense of worth
and their ability to relate to others.'~
Some specialized groups composed of individuals for whom
secrecy
has been an especially important and isolating factor place a
particularly
great emphasis on universality. For example, short-term
structured groups
for bulimic clients build into their protocol a strong requirement
for self-
disclosure, especially disclosure about attitudes toward body
image and
detailed accounts of each member's eating rituals and purging
practices.
With rare exceptions, patients express great relief at discovering
that they
are not alone, that others share the same dilemmas and life
experiences.19
'There are several methods of using such information in the
work of the group. One effective
technique is to redistribute the anonymous secrets to the
members, each one receiving another's
secret. Each member is then asked to read the secret aloud and
reveal how he or she would feel
if harboring such a secret. This method usually proves to be a
valuable demonstration of uni-
versaliry, empathy, and the ability of others to understand.

https://experiences.19
Members of sexual abuse groups, too, profit enormously from
the ex-
perience of universality. 20 An integral part of these groups is
the intimate
sharing, often for the first time in each member's life, of the
details of the
abuse and the ensuing internal devastation they suffered.
Members in
such groups can encounter others who have suffered similar
violations as
children, who were not responsible for what happened to them,
and who
have also suffered deep feelings of shame, guilt, rage, and
uncleanness. A
feeling of universality is often a fundamental step in the therapy
of clients
burdened with shame, stigma, and self-blame, for example,
clients with
HIV/AIDS or those dealing with the aftermath of a suicide. 21
Members of homogeneous groups can speak to one another with
a
powerful authenticity that comes from their firsthand experience
in ways
that therapists may not be able to do. For instance, I once
supervised a
thirty-five-year-old therapist who was leading a group of
depressed men
in their seventies and eighties. At one point a seventy-seven-
year-old man

who had recently lost his wife expressed suicidal thoughts. The
therapist
hesitated, fearing that anything he might say would come across
as naive.
Then a ninety-one-year-old group member spoke up and
described how
he had lost his wife of sixty years, had plunged into a suicidal
despair, and
had ultimately recovered and returned to life. That statement
resonated
deeply and was not easily dismissed.
In multicultural groups, therapists may need to pay particular
attention
to the clinical factor of universality. Cultural minorities in a
predomi-
nantly Caucasian group may feel excluded because of different
cultural
attitudes toward disclosure, interaction, and affective
expression. Thera-
pists must help the group move past a focus on concrete cultural
differ-
ences to transcultural-that is, universal-responses to human
situations
and tragedies. 22 At the same time, therapists must be keenly
aware of the
cultural factors at play. Mental health professionals are often
sorely lack-
ing in knowledge of the cultural facts of life required to work
effectively
with culturally diverse members. It is imperative that therapists
learn as
much as possible about their clients' cultures as well as their
attachment
to or alienation from their culture. 23

Universality, like the other therapeutic factors, does not have
sharp bor-
ders; it merges with other therapeutic factors. As clients
perceive their
similarity to others and share their deepest concerns, they
benefit further
from the accompanying catharsis and from their ultimate
acceptance by
other members (see chapter 3 on group cohesiveness).
IMPARTING INFORMATION
Under the general rubric of imparting information, I include
didactic in-
struction about mental health, mental illness, and general
psychodynam-
https://culture.23
https://tragedies.22
https://suicide.21
https://universality.20
9 Imparting Information
ics given by the therapists as well as advice, suggestions, or
direct guid-
ance from either the therapist or other group members.
Didactic Instruction
Most pa'rticipants, at the conclusion of successful interactional
group
therapy, have learned a great deal about psychic functioning,
the meaning
of symptoms, interpersonal and group dynamics, and the process

of psy-
chotherapy. Generally, the educational process is implicit; most
group
therapists do not offer explicit didactic instruction in
interactional group
therapy. Over the past decade, however, many group therapy
approaches
have made formal instruction, or psychoeducation, an important
part of
the program.
One of the more powerful historical precedents for
psychoeducation
can be found in the work of Maxwell Jones, who in his work
with large
groups in the 1940s lectured to his patients three hours a week
about the
nervous system's structure, function, and relevance to
psychiatric symp-
toms and disability.24
Marsh, writing in the 1930s, also believed in the importance of
psy-
choeducation and organized classes for his patients, complete
with lec-
tures, homework, and grades.25
Recovery, Inc., the nation's oldest and largest self-help program
for cur-
rent and former psychiatric patients, is basically organized
along didactic
lines. 26 Founded in 1937 by Abraham Low, this organizatio n
has over 700
operating groups today. 27 Membership is voluntary, and the
leaders spring
from the membership. Although there is no formal professional

guidance,
the conduct of the meetings has been highly structured by Dr.
Low; parts
of his textbook, Me_ntal Health Through Will Training, 28 are
read aloud
and discussed at every meeting. Psychological illness is
explained on the
basis of a few simple principles, which the members memorize-
for ex-
ample, the value of "spotting" troublesome and self-
undermining behav-
iors; that neurotic symptoms are distressing but not dangerous;
that
tension intensifies and sustains the symptom and should be
avoided; that
the use of one's free will is the solution to the nervous patient's
dilemmas.
Many other self-help groups strongly emphasize the imparting
of in-
formation. Groups such as Adult Survivors of Incest, Parents
Anony-
mous, Gamblers Anonymous, Make Today Count (for cancer
patients),
Parents Without Partners, and Mended Hearts encourage the
exchange of
information among members and often invite experts to address
the
group. 29 The group environment in which learning takes place
is impor-
tant. The ideal context is one of partnership and collaboration,
rather
than prescription and subordination.
Recent group therapy literature abounds with descriptions of
special-

ized groups for individuals who have some specific disorder or
face some
https://group.29
https://today.27
https://lines.26
https://grades.25
https://disability.24
definitive life crisis-for example, panic disorder,30 obesity, 31
bulimia,32
adjustment after divorce, 33 herpes,34 coronary heart disease,35
parents of
sexually abused children,36 male batterers,37 bereavement,38
HIV/AIDS,39
sexual dysfunction, 40 rape, 41 self-image adjustment after
mastectomy,42
chronic pain,43 organ transplant,44 and prevention of
depression relapse. 45
In addition to offering mutual support, these groups generally
build in
a psychoeducational component approach offering explicit
instruction
about the nature of a client's illness or life situation and
examining
clients' misconceptions and self-defeating responses to their
illness. For
example, the leaders of a group for clients with panic disorder
describe
the physiological cause of panic attacks, explaining that
heightened
stress and arousal increase the flow of adrenaline, which may

result in
hyperventilation, shortness of breath, and dizziness; the client
misinter-
prets the symptoms in ways that only exacerbate them ("I'm
dying" or
"I'm going crazy"), thus perpetuating a vicious circle. The
therapists dis-
cuss the benign nature of panic attacks and offer instruction
first on how
to bring on a mild attack and then on how to prevent it. They
provide de-
tailed instruction on proper breathing techniques and
progressive muscu-
lar relaxation.
Groups are often the setting in which new mindfulness- and
medita-
tion-based stress reduction approaches are taught. By applying
disciplined
focus, members learn to become clear, accepting, and
nonjudgmental ob-
servers of their thoughts and feelings and to reduce stress,
anxiety, and
vulnerability to depression. 46
Leaders of groups for HIV-positive clients frequently offer
considerable
illness-related medical information and help correct members'
irrational
fears and misconceptions about infectiousness. They may also
advise
members about methods of informing others of their condition
and fash-
ioning a less guilt-provoking lifestyle.
Leaders of bereavement groups may provide information about

the
natural cycle of bereavement to help members realize that there
is a se-
quence of pain through which they are progressing and there
will be a
natural, almost inevitable, lessening of their distress as they
move through
the stages of this sequence. Leaders may help clients anticipate,
for exam-
ple, the acute anguish they will feel with each significant date
(holidays,
anniversaries, and birthdays) during the first year of
bereavement. Psy-
choeducational groups for women with primary breast cancer
provide
members with information about their illness, treatment options,
and fu-
ture risks as well as recommendations for a healthier lifestyle.
Evaluation
of the outcome of these groups shows that participants
demonstrate sig-
nificant and enduring psychosocial benefits.47
Most group therapists use some form of anticipatory guidance
for
clients about to enter the frightening situation of the
psychotherapy
https://benefits.47
https://depression.46
https://relapse.45
11 Imparting Information
group, such as a preparatory session intended to clarify

important rea-
sons for psychological dysfunction and to provide instruction in
meth-
ods of self-exploration. 48 By predicting clients' fears, by
providing them
with a cognitive structure, we help them cope more effectively
with the
culture shock they may encounter when they enter the group
therapy
(see chapter 10).
Didactic instruction has thus been employed in a variety of
fashions in
group therapy: to transfer information, to alter sabotaging
thought pat-
terns, to structure the group, to explain the process of illness.
Often such
instruction functions as the initial binding force in the group,
until other
therapeutic factors become operative. In part, however,
explanation and
clarification function as effective therapeutic agents in their
own right.
Human beings have always abhorred uncertainty and through
the ages
have sought to order the universe by providing explanations,
primarily re-
ligious or scientific. The explanation of a phenomenon is the
first step to-
ward its control. If a volcanic eruption is caused by a displeased
god, then
at least there is hope of pleasing the god.
Frieda Fromm-Reichman underscores the role of uncertainty in
pro-
ducing anxiety. The awareness that one is not one's own

helmsman, she
points out, that one's perceptions and behavior are controlled by
irra-
tional forces, is itself a common and fundamental source of
anxiety. 49
Our contemporary world is one in which we are forced to
confront fear
and anxiety often. In particular, the events of September 11,
2001, have
brought these troubling emotions more clearly to the forefront
of people's
lives. Confronting traumatic anxieties with active coping (for
instance,
engaging in life, speaking openly, and providing mutual
support), as op-
posed to withdrawing in demoralized avoidance, is enormously
helpful.
These responses not only appeal to our common sense but, as
contempo-
rary neurobiological research demonstrates, these forms of
active coping
activate important neural circuits in the brain that help regulate
the
body's stress reactions.50
And so it is with psychotherapy clients: fear and anxiety that
stem from
uncertainty of the source, meaning, and seriousness of
psychiatric symp- ·
toms may so compound the total dysphoria that effective
exploration be-
comes vastly more difficult. Didactic instruction, through its
provision of
structure and explanation, has intrinsic value and deserves a
place in our

repertoire of therapeutic instruments (see chapter 5).
Direct Advice
Unlike explicit didactic instruction from the therapist, direct
advice from
the members occurs without exception in every therapy group.
In dy-
namic interactional therapy groups, it is invariably part of the
early life of
the group and occurs with such regularity that it can be used to
estimate
https://reactions.50
https://anxiety.49
https://self-exploration.48
a group's age. If I observe or hear a tape of a group in w hich the
clients
with some regularity say things like, "I think you ought to ... "
or "What
you should do is ..." or "Why don't you ... ?" then I can be
reasonably
certain either that the group is young or that it is an older group
facing
some difficulty that has impeded its development or effected
temporary
regression. In other words, advice-giving may reflect a
resistance to more
intimate engagement in which the group members attempt to
manage re-
lationships rather than to connect. Although advice-giving is
common in

early interactional group therapy, it is rare that specific advice
will directly
benefit any client. Indirectly, however, advice-giving serves a
purpose; the
process of giving it, rather than the content of the advice, may
be benefi-
cial, implying and conveying, as it does, mutual interest and
caring.
Advice-giving or advice-seeking behavior is often an important
clue in
the elucidation of interpersonal pathology. The client who, for
example,
continuously pulls advice and suggestions from others,
ultimately only to
reject them and frustrate others, is well known to group
therapists as the
"help-rejecting complainer" or the "yes ... but" client (see
chapter 13).51
Some group members may bid for attention and nurturance by
asking for
suggestions about a problem that either is insoluble or has
already been
solved. Others soak up advice with an unquenchable thirst, yet
never rec-
iprocate to others who are equally needy. Some group members
are so in-
tent on preserving a high-status role in the group or a facade of
cool
self-sufficiency that they never ask directly for help; some are
so anxious
to please that they never ask for anything for themselves; some
are exces-
sively effusive in their gratitude; others never acknowledge the
gift but

take it home, like a bone, to gnaw on privately.
Other types of more structured groups that do not focus on
member
interaction make explicit and effective use of direct suggestions
and guid-
ance. For example, behavior-shaping groups, hospital discharge
planning
and transition groups, life skills groups, communicational skills
groups,
Recovery, Inc., and Alcoholics Anonymous all proffer
considerable direct
advice. One communicational skills group for clients who have
chronic
psychiatric illnesses reports excellent results with a structured
group pro-
gram that includes focused feedback, videotape playback, and
problem-
solving projects. 52 AA makes use of guidance and slogans: for
example,
members are asked to remain abstinent for only the next twenty-
four
hours-"One day at a time." Recovery, Inc. teaches members how
to spot
neurotic symptoms, how to erase and retrace, how to rehearse
and re-
verse, and how to apply willpower effectively.
Is some advice better than others? Researchers who studied a
behavior-
shaping group of male sex offenders noted that advice was
common and
was useful to different members to different extents. The least
effective
form of advice was a direct suggestion; most effective was a
series of al-

https://projects.52
13 Altruism
ternative suggestions about how to achieve a desired goal. 53
Psychoeduca-
tion about the impact of depression on family relationships is
much more
effective when participants examine, on a direct, emotional
level, the way
depression is affecting their own lives and family relationships.
The same
information presented in an intellectualized and detached
manner is far
less valuable,54
ALTRUISM
There is an old Hasidic story of a rabbi who had a conversation
with the
Lord about Heaven and Hell. "I will show you Hell," said the
Lord, and
led the rabbi into a room containing a group of famished,
desperate peo-
ple sitting around a large, circular table. In the center of the
table rested
an enormous pot of stew, more than enough for everyone. The
smell of
the stew was delicious and made the rabbi's mouth water. Yet
no one ate.
Each diner at the table held a very long-handled spoon-long
enough to
reach the pot and scoop up a spoonful of stew, but too long to
get the

food into one's mouth. The rabbi saw that their suffering was
indeed ter-
rible and bowed his head in compassion. "Now I will show you
Heaven,"
said the Lord, and they entered another room, identical to the
first-same
large, round table, same enormous pot of stew, same long-
handled
spoons. Yet there was gaiety in the air; everyone appeared well
nourished,
plump, and exuberant. The rabbi could not understand and
looked to the
Lord. "It is simple," said the Lord, "but it requires a certain
skill. You see,
the people in this room have learned to feed each other!"~·
In therapy groups, as well as in the story's imagined Heaven and
Hell,
members gain through giving, not only in receiving help as part
of the rec-
iprocal giving-receiving sequence, but also in profiting from
something in-
trinsic to the act of giving. Many psychiatric patients beginning
therapy
are demoralized and possess a deep sense of having nothing of
value to
offer others. They have long considered themselves as burdens,
and the
experience of finding that they can be of importance to others is
refresh-
ing and boosts self-esteem. Group therapy is unique in being the
only
therapy that offers clients the opportunity to be of benefit to
others. It
also encourages role versatility, requiring clients to shift
between roles of

help receivers and help providers. 55
*In 1973, a member opened the first meeting of the first group
ever offered for advanced cancer
patients by distributing this parable to the other members of the
group. This woman (whom I've
written about elsewhere, referring to her as Paula West; see I.
Yalom, Momma and the Mean-
ing of Life [New York: Basic Books, 1999]) had been involved
with me from the beginning in
conceptualizing and organizing this group (see also chapter 15) .
Her parable proved to be pre-
scient, since many members were to benefit from th~
therapeutic factor of altruism.
And, of course, clients are enormously helpful to one another in
the
group therapeutic process. They offer support, reassurance,
suggestions,
insight; they share similar problems with one another. Not
infrequently
group members will accept observations from another member
far more
readily than from the group therapist. For many clients, the
therapist re-
mains the paid professional; the other members represent the
real world
and can be counted on for spontaneous and truthful reactions
and feed-
back. Looking back over the course of therapy, almost all group
members
credit other members as having been important in their

improvement.
Sometimes they cite their explicit support and advice,
sometimes their
simply having been present and allowing their fellow members
to grow as
a result of a facilitative, sustaining relationship. Through the
experience
of altruism, group members learn firsthand that they have
obligations to
those from whom they wish to receive care.
An interaction between two group members is illustrative.
Derek, a
chronically anxious and isolated man in his forties who had
recently
joined the group, exasperated the other members by consistently
dismiss-
ing their feedback and concern. In response, Kathy, a thirty-
five-year-old
woman with chronic depression and substance abuse problems,
shared
with him a pivotal lesson in her own group experience. For
months she
had rebuffed the concern others offered because she felt she did
not merit
it. Later, after others informed her that her rebuffs were hurtful
to them,
she made a conscious decision to be more receptive to gifts
offered her
and soon observed, to her surprise, that she began to feel much
better. In
other words, she benefited not only from the support received
but also in
her ability to help others feel they had something of value to
offer. She
hoped that Derek could consider those possibilities for himself.

Altruism is a venerable therapeutic factor in other systems of
healing. In
primitive cultures, for example, a troubled person is often given
the task of
preparing a feast or performing some type of service for the
community. 56
Altruism plays an important part in the healing process at
Catholic
shrines, such as Lourdes, where the sick pray not only for
themselves but
also for one another. People need to feel they are needed and
useful. It is
commonplace for alcoholics to continue their AA contacts for
years after
achieving complete sobriety; many members have related their
cautionary
story of downfall and subsequent reclamation at least a
thousand times
and continually enjoy the satisfaction of offering help to others.
Neophyte group members do not at first appreciate the healing
impact
of other members. In fact, many prospective candidates resist
the sugges-
tion of group therapy with the question "How can the blind lead
the
blind?" or "What can I possibly get from others who are as
confused as I
am? We'll end up pulling one another down." Such resistance is
best
worked through by exploring a client's critical self-evaluation.
Generally,
https://community.56

15 The Corrective Recapitulation of the Primary Family Group
an individual who deplores the prospect of getting help from
other group
members is really saying, "I have nothing of value to offer
anyone."
There is another, more subtle benefit inherent in the altruistic
act.
Many clients who complain of meaninglessness are immersed in
a morbid
self-absorption, which takes the form of obsessive introspection
or a
teeth-gritting effort to actualize oneself. I agree with Victor
Frankl that a
sense of life meaning ensues but cannot be deliberately purs ued:
life
meaning is always a derivative phenomenon that materializes
when we
have transcended ourselves, when we have forgotten ourselves
and become
absorbed in someone (or something) outside ourselves.57 A
focus on life
meaning and altruism are particularly important components of
the
group psychotherapies provided to patients coping with life-
threatening
medical illnesses such as cancer and AIDS. t 58
THE CORRECTIVE RECAPITULATION OF
THE PRIMARY FAMILY GROUP
The great majority of clients who enter groups-with the
exception of

those suffering from posttraumatic stress disorder or from some
medical
or environmental stress-have a background of a highly
unsatisfactory
experience in their first and most important group: the primary
family.
The therapy group resembles a family in many aspects: there are
author-
ity/parental figures, peer/sibling figures, deep personal
revelations, strong
emotions, and deep intimacy as well as hostile, competitive
feelings. In
fact, therapy groups are often led by a male and female therapy
team in a
deliberate effort to simulate the parental configuration as
closely as possi-
ble. Once the initial discomfort is overcome, it is inevitable
that, sooner or
later, the members will interact with leaders and other members
in modes
reminiscent of the way they once interacted with parents and
siblings.
If the group leaders are seen as parental figures, then they will
draw re-
actions associated with parental/authority figures: some
members become
helplessly dependent on the leaders, whom they imbue with
unrealistic
knowledge and power; others blindly defy the leaders, who are
perceived
as infantilizing and controlling; others are wary of the leaders,
who they
believe attempt to strip members of their individuality; some
members try
to split the co-therapists in an attempt to incite parental

disagreements
and rivalry; some disclose most deeply when one of the co-
therapists is
away; some compete bitterly with other members, hoping to
accumulate
units of attention and caring from the therapists; some are
enveloped in
envy when the leader's attention is focused on others: others
expend en-
ergy in a search for allies among the other members, in order to
topple the
therapists; still others neglect their own interests in a seemingly
selfless ef-
fort to appease the leaders and the other members.
https://ourselves.57
Obviously, similar phenomena occur in individual therapy, but
the
group provides a vastly greater number and variety of
recapitulative pos-
sibilities. In one of my groups, Betty, a member who had been
silently
pouting for a couple of meetings, bemoaned the fact that she
was not in
one-to-one therapy. She claimed she was inhibited because she
knew the
group could not satisfy her needs. She knew she could speak
freely of her-
self in a private conversation with the therapist or with any one
of the
members. When pressed, Betty expressed her irritation that
others were

favored over her in the group. For example, the group had
recently wel-
comed another member who had returned from a vacation,
whereas her
return from a vacation went largely unnoticed by the group.
Furthermore,
another group member was praised for offering an important
interpreta-
tion to a member, whereas she had made a similar statement
weeks ago
that had gone unnoticed. For some time, too, she had noticed
her growing
resentment at sharing the group time; she was impatient while
waiting for
the floor and irritated whenever attention was shifted away fr om
her.
Was Betty right? Was group therapy the wrong treatment for
her? Ab-
solutely not! These very criticisms-which had roots stretching
down into
her early relationships with her siblings-did not constitute valid
objec-
tions to group therapy. Quite the contrary: the group format was
particu-
larly valuable for her, since it allowed her envy and her craving
for
attention to surface. In individual therapy-where the therapist
attends to
the client's every word and concern, and the individual is
expected to use
up all the allotted time-these particular conflicts might emerge
belatedly,
if at all.
What is important, though, is not only that early familial

conflicts are
relived but that they are relived correctively. Reexposure
without repair
only makes a bad situation worse. Growth-inhibiting
relationship pat-
terns must not be permitted to freeze into the rigid,
impenetrable system
that characterizes many family structures. Instead, fixed roles
must be
constantly explored and challenged, and ground rules that
encourage the
investigation of relationships and the testing of new behavior
must be es-
tablished. For many group members, then, working out
problems with
therapists and other members is also working through
unfinished business
from long ago. (How explicit the working in the past need be is
a complex
and controversial issue, which I will address in chapter 5.)
DEVELOPMENT OF SOCIALIZING TECHNIQUES
Social learning-the development of basic social skills-is a
therapeutic
factor that operates in all therapy groups, although the nature of
the skills
taught and the explicitness of the process vary greatly,
depending on the
type of group therapy. There may be explicit emphasis on the
develop-
17 Imitative Behavior

ment of social skills in, for example, groups preparing
hospitalized pa-
tients for discharge or adolescent groups. Group members may
be asked
to role-play approaching a prospective employer or asking
someone out
on a date.
In other groups, social learning is more indirect. Members of
dynamic
therapy groups, which have ground rules encouraging open
feedback, may
obtain considerable information about maladaptive social
behavior. A
member may, for example, learn about a disconcerting tendency
to avoid
looking at the person with whom he or she is conversing; about
others'
impressions of his or her haughty, regal attitude; or about a
variety of
other social habits that, unbeknownst to the group member, have
been
undermining social relationships. For individuals lacking
intimate rela-
tionships, the group often represents the first opportunity for
accurate in-
terpersonal feedback. Many lament their inexplicable
loneliness: group
therapy provides a rich opportunity for members to learn how
they con-
tribute to their own isolation and loneliness. 59
One man, for example, who had been aware for years that others
avoided social contact with him, learned in the therapy group
that his ob-
sessive inclusion of minute, irrelevant details in his social

conversation
was exceedingly off-putting. Years later he told me that one of
the most
important events of his life was when a group member (whose
name he
had long since forgotten) told him, "When you talk about your
feelings, I
like you and want to get closer; but when you start talking about
facts and
details, I want to get the hell out of the room!"
I do not mean to oversimplify; therapy is a complex process and
obvi-
ously involves far more than the simple recognition and
conscious, delib-
erate alteration of social behavior. But, as I will show in
chapter 3, these
gains are more than fringe benefits; they are often instrumental
in the ini-
tial phases of therapeutic change. They permit the clients to
understand
that there is a huge discrepancy between their intent and their
actual im-
pact on others. t
Frequently senior members of a therapy group acquire highly
sophisti-
cated social skills: they are attuned to process (see chapter 6);
they have
learned how to be helpfully responsive to others; they have
acquired meth-
ods of conflict resolution; they are less likely to be judgmental
and are
more capable of experiencing and expressing accurate empathy.
These
skills cannot but help to serve these clients well in future social

interac-
tions, and they constitute the cornerstones of emotional
intelligence. 60
IMITATIVE BEHAVIOR
Clients during individual psychotherapy may, in time, sit, walk,
talk, and
even think like their therapists. There is considerable evidence
that group
https://intelligence.60
https://loneliness.59
therapists influence the communicational patterns in their
groups by
modeling certain behaviors, for example, self-disclosure or
support. 61 In
groups the imitative process is more diffuse: clients may model
them-
selves on aspects of the other group members as well as of the
thera-
pist. 62 Group members learn from watching one another tackle
problems. This may be particularly potent in homogeneous
groups that
focus on shared problems-for example, a cognitive-behavior
group that
teaches psychotic patients strategies to reduce the intensity of
auditory
hallucinations. 63
The importance of imitative behavior in the therapeutic process
is dif-

ficult to gauge, but social-psychological research suggests that
therapists
may have underestimated it. Bandura, who has long claimed that
social
learning cannot be adequately explained on the basis of direct
reinforce-
ment, has experimentally demonstrated that imitation is an
effective ther-
apeutic force.t 64 In group therapy it is not uncommon for a
member to
benefit by observing the therapy of another member with a
similar prob-
lem constellation-a phenomenon generally referred to as
vicarious or
spectator therapy. 65
Imitative behavior generally plays a more important role in the
early
stages of a group, as members identify with more senior
members or ther-
apists. 66 Even if imitative behavior is, in itself, short-lived, it
may help to
unfreeze the individual enough to experiment with new
behavior, which
in turn can launch an adaptive spiral (see chapter 4). In fact, it
is not un-
common for clients throughout therapy to "try on," as it were,
bits and
pieces of other people and then relinquish them as ill fitting.
This process
may have solid therapeutic impact; finding out what we are not
is progress
toward finding out what we are.
https://therapy.65
https://support.61

Group therapy can alleviate feelings of isolation and foster a
supportive and collaborative environment for sharing difficult
feelings in order to facilitate healing. For many people, being
part of a group that has a shared understanding of a struggle
provides a unique opportunity to gain understanding of their
own experiences.
As you examine one of the group therapy demonstrations from
this week’s Learning Resources, consider the role and efficacy
of the leader and the reasons that specific therapeutic
techniques were selected.
To prepare:
· Select one of the group therapy video demonstrations from
this week’s required media Learning Resources.
The Assignment
In a 3- to 4-page paper, identify the video you selected and
address the following:
· What group therapy techniques were demonstrated? How well
do you believe these techniques were demonstrated?
· What evidence from the literature supports the techniques
demonstrated?
· What did you notice that the therapist did well?
· Explain something that you would have handled differently.
· What is an insight that you gained from watching the therapist
handle the group therapy?
· Now imagine you are leading your own group session. How
would you go about handling a difficult situation with a
disruptive group member? How would you elicit participation in
your group? What would you anticipate finding in the different
phases of group therapy? What do you see as the benefits and
challenges of group therapy?
· Support your reasoning with at least three peer-reviewed,
evidence-based sources, and explain why each of your
supporting sources is considered scholarly. Attach the PDFs of
your sources.

Reminder The School of Nursing requires that all papers
submitted include a title page, introduction, summary, and
references. The Sample Paper provided at the Walden Writing
Center provides an example of those required elements
(available at http://writingcenter.waldenu.edu/57.htm). All
papers submitted must use this formatting.
PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED
BELOW:
1). ZERO (0) PLAGIARISM
2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS.
3). PLEASE SEE THE ATTACHED RUBRIC AND THE
GRADING DETAILS. SEE THE REQUIRED VIDEOS LINKS
ATTACHED.
4). PLEASE FOLLOW THE APA 7 WRITING RULES, STYLE,
AND FORMAT. PLEASE INCLUDE CONCLUSION.
Thank you.
Rubric Detail
Select Grid View or List View to change the rubric's layout.
Content
Name: NRNP_6645_Week3_Assignment_Rubric
Grid ViewList View
Excellent
90%–100%

Good
80%–89%
Fair
70%–79%
Poor
0%–69%
Develop a 3- to 4-page paper considering the role and efficacy
of the leader of a group therapy demonstration. Be sure to
· Describe the group therapy techniques that were
demonstrated and evaluate how well they were demonstrated.
. Include evidence from the literature that supports the use of
the demonstrated techniques.
Points:
Points Range:

23 (23%) - 25 (25%)
The response accurately and thoroughly describes and
evaluates the efficacy of the group therapy techniques that were
demonstrated in the video.
The response includes accurate, clear, and detailed evidence
from the literature that supports the use of the demonstrated
techniques.
Feedback:
Points:

Points Range:
20 (20%) - 22 (22%)
The response accurately describes and evaluates the efficacy
of the group therapy techniques that were demonstrated in the
video.
The response includes evidence from the literature that supports
the use of the demonstrated techniques.
Feedback:

Points:
Points Range:
18 (18%) - 19 (19%)
The response includes a somewhat vague or inaccurate
description and evaluation of the group therapy techniques that
were demonstrated in the video.
The response includes somewhat vague or inaccurate evidence
from the literature to support the use of the demonstrated
techniques.
Feedback:

Points:
Points Range:
0 (0%) - 17 (17%)
The description and evaluation of the group therapy techniques
that were demonstrated in the video are vague and inaccurate, or
missing.
The response includes vague and inaccurate evidence from the
literature to support the use of the demonstrated techniques, or
is missing.

Feedback:
· Identify what the therapist did well.
· Identify an insight that you gained form watching the
therapist handle the group therapy.
Points:
Points Range:
23 (23%) - 25 (25%)

The response accurately and thoroughly explains in detail what
the therapist did well.
The response accurately and thoroughly explains something that
could have been handled differently.
The response accurately and thoroughly explains an insight
gained from watching the therapist handle the group therapy.
Feedback:
Points:

Points Range:
20 (20%) - 22 (22%)
The response accurately explains in detail what the therapist
did well.
The response accurately explains something that could have
been handled differently.
The response accurately explains an insight gained from
watching the therapist handle the group therapy.
Feedback:

Points:
Points Range:
18 (18%) - 19 (19%)
The response somewhat vaguely or inaccurately explains in
detail what the therapist did well.
The response somewhat vaguely or inaccurately explains
something that could have been handled differently.
The response somewhat vaguely or inaccurately explains an
insight gained from watching the therapist handle the group
therapy.

Feedback:
Points:
Points Range:
0 (0%) - 17 (17%)
The response vaguely or inaccurately explains in detail what
the therapist did well, or is missing.

The response vaguely or inaccurately explains something that
could have been handled differently, or is missing.
The response vaguely or inaccurately explains an insight gained
from watching the therapist handle the group therapy, or is
missing.
Feedback:
Imagine that you are leading your own group session.
· Describe how would you go about handling a difficult group
member.
· Explain how you would elicit participation in your group.
· Describe what you would anticipate to find in different
phases of the group therapy.
· Explain the benefits and challenges of group therapy.

Points:
Points Range:
23 (23%) - 25 (25%)
The response includes a detailed and accurate description of
how to handle a difficult group member.
The response accurately and thoroughly explains how to elicit
participation in group therapy.
The response thoroughly and accurately describes anticipated
findings in different phases of group therapy.
The response includes a thorough and accurate explanation the
benefits and challenges of group therapy.

Feedback:
Points:
Points Range:
20 (20%) - 22 (22%)
The response includes a description of how to handle a
difficult group member.

The response explains how to elicit participation in group
therapy.
The response describes anticipated findings in different phases
of group therapy.
The response explains the benefits and challenges of group
therapy.
Feedback:
Points:

Points Range:
18 (18%) - 19 (19%)
description of how to handle a difficult group member.
The response somewhat vaguely or inaccurately explains how to
elicit participation in group therapy.
The response somewhat vaguely or inaccurately describes
anticipated findings in different phases of group therapy.
explaination of the benefits and challenges of group therapy.
Feedback:

Points:
Points Range:
0 (0%) - 17 (17%)
The response includes a vague or inaccurate description of
how to handle a difficult group member, or is missing.
The response vaguely or inaccurately explains how to elicit
participation in group therapy, or is missing.
The response vaguely or inaccurately describes anticipated

findings in different phases of group therapy, or is missing.
The response includes a vague or inaccurate explaination the
benefits and challenges of group therapy, or is missing.
Feedback:
• Support your reasoning with at least three peer-reviewed,
evidence-based sources and explain why each of your
your sources.
Points:
Points Range:

9 (9%) - 10 (10%)
Three peer-reviewed, evidence-based sources are used to
support the assignment. Resources selected provide strong
justification for reasoning and represent the latest in standards
of care.
Feedback:
Points:

Points Range:
8 (8%) - 8 (8%)
support the assignment. Resources selected provide appropriate
of care.
Feedback:
Points:

Points Range:
7 (7%) - 7 (7%)
Two peer-reviewed, evidence-based sources are used to
of care. Or, three scholarly resources are used to support the
assignment, but provide only weak support for reasoning or do
not represent the latest in standards of care.
Feedback:
Points:

Points Range:
0 (0%) - 6 (6%)
Resources selected are not peer reviewed and evidence based,
or provide poor justification for reasoning. Or, resources are
missing.
Feedback:
Written Expression and Formatting - Paragraph Development
and Organization:
Paragraphs make clear points that support well-developed ideas,
flow logically, and demonstrate continuity of ideas. Sentences
are carefully focused—neither long and rambling nor short and
lacking substance. A clear and comprehensive purpose
statement and introduction is provided which delineates all

required criteria.
Points:
Points Range:
5 (5%) - 5 (5%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and
conclusion are provided that delineates all required criteria.
Feedback:

Points:
Points Range:
4 (4%) - 4 (4%)
continuity, and clarity 80% of the time.
Purpose, introduction, and conclusion of the assignment are
stated, yet are brief and not descriptive.

Feedback:
Points:
Points Range:
3.5 (3.5%) - 3.5 (3.5%)
continuity, and clarity 60%–79% of the time.

vague or off topic.
Feedback:
Points:
Points Range:
0 (0%) - 3 (3%)

continuity, and clarity < 60% of the time.
No purpose statement, introduction, or conclusion were
provided.
Feedback:
Written Expression and Formatting - English writing
standards:
Correct grammar, mechanics, and proper punctuation
Points:
Points Range:
5 (5%) - 5 (5%)

Uses correct grammar, spelling, and punctuation with no
errors.
Feedback:
Points:
Points Range:
4 (4%) - 4 (4%)

Contains 1 or 2 grammar, spelling, and punctuation errors.
Feedback:
Points:
Points Range:
3.5 (3.5%) - 3.5 (3.5%)

Feedback:
Points:
Points Range:
0 (0%) - 3 (3%)

Contains many (≥ 5) grammar, spelling, and punctuation errors
that interfere with the reader’s understanding.
Feedback:
Written Expression and Formatting - The paper follows correct
APA format for title page, headings, font, spacing, margins,
indentations, page numbers, parenthetical/in-text citations, and
reference list.
Points:
Points Range:
5 (5%) - 5 (5%)

Uses correct APA format with no errors.
Feedback:
Points:
Points Range:
4 (4%) - 4 (4%)

Contains 1 or 2 APA format errors.
Feedback:
Points:
Points Range:
3.5 (3.5%) - 3.5 (3.5%)

Feedback:
Points:
Points Range:
0 (0%) - 3 (3%)

Contains many (≥ 5) APA format errors.
Feedback:
Show Descriptions
Show Feedback
Develop a 3- to 4-page paper considering the role and efficacy
of the leader of a group therapy demonstration. Be sure to
· Describe the group therapy techniques that were
demonstrated and evaluate how well they were demonstrated.
. Include evidence from the literature that supports the use of
the demonstrated techniques.--

Levels of Achievement:
Excellent
90%–100%
23 (23%) - 25 (25%)
The response accurately and thoroughly describes and evaluates
the efficacy of the group therapy techniques that were
demonstrated in the video.
The response includes accurate, clear, and detailed evidence
from the literature that supports the use of the demonstrated
techniques.
Good
80%–89%
20 (20%) - 22 (22%)
The response accurately describes and evaluates the efficacy of
the group therapy techniques that were demonstrated in the
video.

The response includes evidence from the literature that supports
the use of the demonstrated techniques.
Fair
70%–79%
18 (18%) - 19 (19%)
description and evaluation of the group therapy techniques that
were demonstrated in the video.
The response includes somewhat vague or inaccurate evidence
from the literature to support the use of the demonstrated
techniques.
Poor
0%–69%
0 (0%) - 17 (17%)
The description and evaluation of the group therapy techniques
that were demonstrated in the video are vague and inaccurate, or

missing.
The response includes vague and inaccurate evidence from the
literature to support the use of the demonstrated techniques, or
is missing.
Feedback:
· Identify what the therapist did well.
· Identify an insight that you gained form watching the
therapist handle the group therapy.--
Excellent
90%–100%
23 (23%) - 25 (25%)

The response accurately and thoroughly explains in detail what
the therapist did well.
The response accurately and thoroughly explains something that
could have been handled differently.
The response accurately and thoroughly explains an insight
gained from watching the therapist handle the group therapy.
Good
80%–89%
20 (20%) - 22 (22%)
The response accurately explains in detail what the therapist did
well.
The response accurately explains something that could have
been handled differently.
The response accurately explains an insight gained from

watching the therapist handle the group therapy.
Fair
70%–79%
18 (18%) - 19 (19%)
The response somewhat vaguely or inaccurately explains in
detail what the therapist did well.
The response somewhat vaguely or inaccurately explains
something that could have been handled differently.
The response somewhat vaguely or inaccurately explains an
insight gained from watching the therapist handle the group
therapy.
Poor
0%–69%
0 (0%) - 17 (17%)

The response vaguely or inaccurately explains in detail what the
therapist did well, or is missing.
The response vaguely or inaccurately explains something that
could have been handled differently, or is missing.
The response vaguely or inaccurately explains an insight gained
from watching the therapist handle the group therapy, or is
missing.
Feedback:
Imagine that you are leading your own group session.
· Describe how would you go about handling a difficult group
member.
· Explain how you would elicit participation in your group.
· Describe what you would anticipate to find in different
phases of the group therapy.

· Explain the benefits and challenges of group therapy.--
Excellent
90%–100%
23 (23%) - 25 (25%)
The response includes a detailed and accurate description of
how to handle a difficult group member.
The response accurately and thoroughly explains how to elicit
participation in group therapy.
The response thoroughly and accurately describes anticipated
findings in different phases of group therapy.
The response includes a thorough and accurate explanation the
benefits and challenges of group therapy.
Good
80%–89%

20 (20%) - 22 (22%)
The response includes a description of how to handle a difficult
group member.
The response explains how to elicit participation in group
therapy.
The response describes anticipated findings in different phases
of group therapy.
The response explains the benefits and challenges of group
therapy.
Fair
70%–79%
18 (18%) - 19 (19%)
description of how to handle a difficult group member.

The response somewhat vaguely or inaccurately explains how to
elicit participation in group therapy.
The response somewhat vaguely or inaccurately describes
anticipated findings in different phases of group therapy.
explaination of the benefits and challenges of group therapy.
Poor
0%–69%
0 (0%) - 17 (17%)
The response includes a vague or inaccurate description of how
to handle a difficult group member, or is missing.
The response vaguely or inaccurately explains how to elicit
participation in group therapy, or is missing.
The response vaguely or inaccurately describes anticipated

findings in different phases of group therapy, or is missing.
The response includes a vague or inaccurate explaination the
benefits and challenges of group therapy, or is missing.
Feedback:
• Support your reasoning with at least three peer-reviewed,
evidence-based sources and explain why each of your
your sources.--
Excellent
90%–100%
9 (9%) - 10 (10%)

support the assignment. Resources selected provide strong
of care.
Good
80%–89%
8 (8%) - 8 (8%)
of care.
Fair
70%–79%
7 (7%) - 7 (7%)
Two peer-reviewed, evidence-based sources are used to support
the assignment. Resources selected provide appropriate
of care. Or, three scholarly resources are used to support the
assignment, but provide only weak support for reasoning or do
not represent the latest in standards of care.

Poor
0%–69%
0 (0%) - 6 (6%)
Resources selected are not peer reviewed and evidence based, or
provide poor justification for reasoning. Or, resources are
missing.
Feedback:
Written Expression and Formatting - Paragraph Development
and Organization:
Paragraphs make clear points that support well-developed ideas,
flow logically, and demonstrate continuity of ideas. Sentences
are carefully focused—neither long and rambling nor short and
lacking substance. A clear and comprehensive purpose
statement and introduction is provided which delineates all
required criteria.--

Excellent
90%–100%
5 (5%) - 5 (5%)
continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and
conclusion are provided that delineates all required criteria.
Good
80%–89%
4 (4%) - 4 (4%)
continuity, and clarity 80% of the time.
stated, yet are brief and not descriptive.

Fair
70%–79%
3.5 (3.5%) - 3.5 (3.5%)
continuity, and clarity 60%–79% of the time.
vague or off topic.
Poor
0%–69%
0 (0%) - 3 (3%)
continuity, and clarity < 60% of the time.
No purpose statement, introduction, or conclusion were
provided.

Feedback:
Written Expression and Formatting - English writing standards:
Correct grammar, mechanics, and proper punctuation--
Excellent
90%–100%
5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Good
80%–89%
4 (4%) - 4 (4%)

Fair
70%–79%
3.5 (3.5%) - 3.5 (3.5%)
Poor
0%–69%
0 (0%) - 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors
that interfere with the reader’s understanding.
Feedback:

Written Expression and Formatting - The paper follows correct
APA format for title page, headings, font, spacing, margins,
indentations, page numbers, parenthetical/in-text citations, and
reference list.--
Excellent
90%–100%
5 (5%) - 5 (5%)
Uses correct APA format with no errors.
Good
80%–89%
4 (4%) - 4 (4%)

Fair
70%–79%
3.5 (3.5%) - 3.5 (3.5%)
Poor
0%–69%
0 (0%) - 3 (3%)
Contains many (≥ 5) APA format errors.
Feedback:

Total Points:
100
Name: NRNP_6645_Week3_Assignment_Rubric
Below are the Required videos.
Please copy and paste the links to watch the videos, then select
one to write on. The transcripts are not available to download as
I used to. Please let me know if there anything you need.
Thank you
https://youtu.be/szS31h0kMI0
https://youtu.be/t8Dzus8WGqA
https://youtu.be/h6CF09f5S1M
https://youtu.be/05Elmr65RDg
https://youtu.be/PwnfWMNbg48

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