The Theory and Practice of Group Psychotherapy 6th Edition

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 Contents

COVER
TITLE PAGE
COPYRIGHT
DEDICATION
PREFACE TO THE SIXTH EDITION
ACKNOWLEDGMENTS

1 THE THERAPEUTIC FACTORS

Instillation of Hope
Universality
Imparting Information
Altruism
The Corrective Recapitulation of the Primary Family Group
Development of Socializing Techniques
Imitative Behavior

2 INTERPERSONAL LEARNING
The Importance of Interpersonal Relationships
The Corrective Emotional Experience
The Group as Social Microcosm
Dynamic Interaction Within the Social Microcosm
Recognition of Behavioral Patterns in the Social Microcosm
The Social Microcosm: Is It Real?
Transference and Insight
Overview
3 GROUP COHESIVENESS
The Importance of Group Cohesiveness
Mechanism of Action
Summary

4 THE THERAPEUTIC FACTORS: AN INTEGRATION

Comparative Value of the Therapeutic Factors: The Client’s View
Comparative Value of the Therapeutic Factors: Differences Between
Clients’ and Therapists’ Views
Therapeutic Factors: Modifying Forces

5 THE THERAPIST: BASIC TASKS

Creation and Maintenance of the Group
Building a Group Culture
How Does the Leader Shape Norms?
Therapeutic Group Norms

6 THE THERAPIST: WORKING IN THE HERE-AND-NOW

Definition of Process
Process Focus: The Power Source of the Group
The Therapist’s Tasks in the Here-and-Now
Techniques of Here-and-Now Activation
Techniques of Process Illumination
Helping Clients Assume a Process Orientation
Helping Clients Accept Process-Illuminating Comments
Process Commentary: A Theoretical Overview
The Use of the Past
Group-as-a-Whole Process Commentary

7 THE THERAPIST: TRANSFERENCE AND TRANSPARENCY

Transference in the Therapy Group
The Psychotherapist and Transparency
 8 SELECTING CLIENTS AND COMPOSING GROUPS
Criteria for Exclusion
Criteria for Inclusion
Summary: Client Selection
Group Composition
The Prediction of Client Behavior in the Group
Summary: Predicting Client Behavior
Principles of Group Composition
Homogeneity or Heterogeneity?
General Clinical Considerations
Summary: Group Composition

9 CREATING THE GROUP

Setting and Structure
Brief Group Therapy
Pregroup Meetings and Preparation for Group Therapy

10 IN THE BEGINNING
Formative Stages of the Group
The Impact of Clients and Other Factors on Group Development
Membership Problems

11 THE ADVANCED GROUP

How Interpersonal Learning Works
Subgrouping
Conflict in the Therapy Group
Self-Disclosure
Termination

12 THE CHALLENGING GROUP MEMBER

The Monopolist
The Silent Client
 The Boring Client
The Help-Rejecting Complainer
The Acutely Psychotic Client
The Schizoid Client
The Characterologically Difficult Client

13 SPECIALIZED FORMATS AND PROCEDURAL AIDS

Concurrent Individual and Group Therapy
Combining Group Therapy and Twelve-Step Groups
Co-Therapy
Dreams
Audiovisual Technology
Written Summaries
Monitoring Group Therapy Outcome and Process
Structured Exercises
Group Therapy Record Keeping

14 ONLINE PSYCHOTHERAPY GROUPS

VTC Groups: Early Findings
Guidelines for Group Psychotherapists
VTC Group Challenges and Opportunities

15 SPECIALIZED THERAPY GROUPS

Modifications for Specialized Clinical Situations: Basic Steps
The Acute Inpatient Therapy Group
Groups for the Medically Ill
Adaptation of CBT and IPT to Group Therapy
Self-Help Groups and Online Support Groups

16 TRAINING THE GROUP THERAPIST

Observation of Experienced Clinicians
Clinical Supervision
 A Group Experience for Trainees
Personal Psychotherapy
Summary
Beyond Technique

DISCOVER MORE
APPENDIX: GROUP THERAPY INFORMATION AND GUIDELINES
FOR CLIENTS
ABOUT THE AUTHORS
NOTES
ALSO BY IRVIN D. YALOM
PRAISE FOR THE THEORY AND PRACTICE OF GROUP
PSYCHOTHERAPY
 IRV YALOM:
I would like to dedicate this book to Marilyn, my beloved
wife of sixty-five years, who died in 2019

MOLYN LESZCZ:
To the next generation: Sid, Pete, Lucy, and Margot
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 Preface to the Sixth Edition

FIFTEEN YEARS HAVE PASSED SINCE THE FIFTH EDITION OF this textbook was
published. Our task in this sixth edition is to describe the new and significant
innovations in group therapy that have emerged during these years. We are
pleased and grateful to continue our long collaboration, which began forty years
ago at Stanford University. We have approached our work together as seasoned
co-therapists and in writing this edition have sought to support and challenge one
another. We write largely as “we,” with an interweaving of both voices. At
certain points, to identify an experience personal to one of us, we switch to first
person and include a parenthetical abbreviation to indicate which of us is taking
over the narration (IY or ML).
Our aim is to provide our readers with a synthesis of new knowledge and
accrued wisdom in the practice of group therapy. We make extensive use of
clinical illustrations to bring these concepts and principles to life and make the
book both practical and instructive. Like previous editions, this one is intended
for students, trainees, and frontline practitioners as well as supervisors and
teachers.
Since group therapy was first introduced in the 1940s, it has continued to
adapt to reflect changes in clinical practice. As new clinical syndromes, settings,
and theoretical approaches have emerged, so have corresponding variants of
group therapy. The multiplicity of forms is so evident today that it makes more
sense to speak of “group therapies” than of “group therapy.” The evidence is
consistently strong, across all ages and clinical needs, that group therapy is
effective, generally with outcomes equivalent to those of individual therapy, and
far less costly. This is true both for mental health and for substance use disorder
treatment as well as for the medically ill.
The Internet makes group therapy far more accessible today than it was in the
predigital world. Geography is no longer the barrier to therapy that it once was.
New technological platforms create new opportunities and challenges for group
therapists: What is the same and what is different as group therapy moves from
the group room to the group screen? These are questions we will address in this
volume in a new chapter focused on online psychotherapy groups (see Chapter
14).
Now, as clients from diverse ethnocultural backgrounds access group
therapy, whether in North America or elsewhere, it is important for therapists to
develop a multicultural orientation as well as sensitivity and expertise in cultural
adaptation. Therapy groups have always been settings for “difficult dialogues”
and discourse; race and gender identity issues can be effectively addressed in a
responsive therapy group environment (see Chapter 16). Group therapy is a
powerful vehicle for working with traumatized and displaced individuals.
Paradoxically, however, professional training for group therapists has failed
to keep pace with the widespread clinical application of the group therapies.
Fewer and fewer training programs—whether in psychology, social work,
counseling, or psychiatry—provide the depth of training and supervision that
future practitioners require. All too often and in too many settings, therapists are
thrust into action—and asked to lead groups of clients with complex histories
and diverse needs—with little training or supervision in group therapy.
Economic pressures, professional turf wars, and the current dominance of
biological explanations and pharmacotherapy in mental health have all
contributed to this situation. Each generation believes naively that it has
discovered the true solution. Mental health is a field uniquely subject to an
oscillation between zealous overvaluation and zealous devaluation, even by its
own practitioners. We are therefore heartened that the American Psychological
Association has recently recognized group psychotherapy as a designated
specialty. This decision will encourage greater investment in education and
training, and we hope it elevates group therapy to the status that its ever-
widening practice warrants. We know that training can be transformative.
Today’s group therapists are influenced by the demand for greater
accountability in practice. Evidence-based practice is a standard to which we
must all adhere. For many years, practitioners resisted this emphasis on using
research, measurement, and data as guides to effective practice as an intrusion
into their work—one that impinged upon their autonomy and thwarted creativity.
But it is anachronistic to think of evidence-based practice as narrowly
prescriptive. We believe that a more effective approach is to embrace evidence-
based practice as a set of guidelines and principles that enhance clinical
effectiveness. Throughout the text we elaborate on the hallmarks of the
evidence-based group therapist: building cohesive groups and strong
relationships, effectively communicating genuine and accurate empathy,
managing countertransference, and maintaining cultural awareness and
sensitivity. Being reflective about our approach to our work and making our
continued professional development a deliberate focus of attention are aspects of
being an evidence-based group therapist. Data collection from our ongoing
groups provides us with timely and relevant feedback about what is actually
happening session to session, client by client (see Chapter 13).
We recognize that group therapists are now using a bewilderingly diverse set
of approaches in their work. Cognitive-behavioral, psychoeducational,
interpersonal, gestalt, supportive-expressive, modern analytic, psychoanalytic,
dynamic-interactional, psychodrama—all of these, and many more, are used in
group therapy today. Group therapists are also bringing advances in our
understanding of human attachment and the neurobiology of interpersonal
relationships to bear in group therapy in an effort to integrate mind, body, and
brain into their work (see Chapters 2 and 3).
Although addressing all these group therapies in a single book presented
challenges, we believe that the strategy guiding the first edition was still sound.
That strategy was to separate “front” from “core” in discussions of each of the
group therapies. The front consists of the trappings, the form, the techniques, the
specialized language, and the aura surrounding any given ideological school; the
core means those aspects of the experience that are intrinsic to the therapeutic
process—that is, the bare-boned mechanisms of change.
If you disregard the “front” and consider only the actual mechanisms of
effecting change in a client, you will find that the change mechanisms are
limited in number and remarkably similar across groups. Therapy groups with
similar goals that appear to be profoundly different if judged only by their
external forms may rely on identical mechanisms of change. These mechanisms
continue to constitute the central organizing principle of this book. We begin
with a detailed discussion of eleven therapeutic factors and then describe a group
psychotherapeutic approach based on them (see Chapters 1, 2, 3, and 4).
Deciding which types of groups to discuss presented another dilemma. The
array of group therapies is now so vast that it is impossible to address each type
of group separately. Instead, we center our discussion on a prototypical situation
—the outpatient psychotherapy group—and then offer a set of principles that
will enable the therapist to modify this fundamental group model to fit any
specialized clinical situation (see Chapter 15).
Our prototypical outpatient psychotherapy group meets for at least several
months with the ambitious goals of both symptomatic relief and personality
change. We describe this group in detail from conception to conclusion,
beginning with the principles of effective selection, group composition, and
preparation (see Chapters 8 and 9), and then moving on to group development,
from the first sessions to the advanced stages of the group, and common clinical
challenges (see Chapters 10, 11, and 12).
Why focus on this particular form of group therapy when the contemporary
therapy scene, driven by economic factors, is dominated by other types of groups
meeting for briefer periods with more limited goals? The answer is that longer-
term group therapy has been around for many decades, and practitioners have
accumulated a vast body of knowledge from both empirical research and
thoughtful clinical observation. We believe that the prototypical group we
describe in this book is an intensive, ambitious form of therapy that demands
much from both client and therapist. This group also affords therapists a unique
lens through which to learn about group process, group dynamics, and group
leadership that will serve them well in all their clinical work. The therapeutic
strategies and techniques required to lead such a group are sophisticated and
complex (see Chapters 5, 6, and 7). However, once students master them and
understand how to modify them to fit specialized therapy situations, they will be
in a position to fashion a group therapy that will be effective for a variety of
clinical populations in different settings.
Trainees should aspire to be creative and compassionate therapists who
understand how to put theory into practice. That requires, in turn, compassionate
supervisors with similar understanding (see Chapter 16). The mounting demand
for clinical care, and the effectiveness and efficiency of group therapy, make it
the treatment modality of the future. Group therapists must be as prepared as
possible for this opportunity. And they need to be able to care well for
themselves, too, so that they can continue to treat others effectively and find
meaning in their work.
Because most readers of this book will be clinicians, this text is intended to
have immediate clinical relevance. We also believe, however, that it is
imperative for clinicians to remain conversant with the world of research. Even
if therapists do not personally engage in research, they must know how to
evaluate the research of others.
One of the most important underlying assumptions in this text is that
interpersonal interaction within the here-and-now is crucial to effective group
therapy. The truly potent therapy group provides an arena in which clients can
interact freely with others and then help members identify and understand what
goes wrong in their interactions. Ultimately, it enables our clients to change
those maladaptive patterns. We believe that groups based solely on other
assumptions, such as psychoeducational or cognitive-behavioral principles, fail
to reap the full therapeutic harvest. Each of these forms of group therapy can be
made more effective by incorporating an awareness of interpersonal process. In
this text we discuss, in depth, the extent and nature of the interactional focus and
its ability to bring about significant character and interpersonal change. The
interactional focus is the engine of group therapy, and therapists who are able to
harness it are much better equipped to do all forms of group therapy, even if the
group model does not emphasize or acknowledge the centrality of interaction
(see Chapter 15).
My (IY) novel The Schopenhauer Cure may serve as a companion volume to
this text. It is set in a therapy group and illustrates many of the principles of
group process and therapist technique described here. Hence, at several points in
this edition, we refer the reader to sections of The Schopenhauer Cure that offer
fictionalized portrayals of therapist techniques.
Excessively overweight volumes tend to end up on the “reference book”
shelves. To avoid that fate we have resisted substantially lengthening this text.
The addition of much new material has thus required us to cut older sections and
citations. This was a painful task, and the deletion of many condemned passages
bruised our hearts as well as our fingers. But we hope the result is a timely and
up-to-date work that will serve students and practitioners well for the next fifteen
years and beyond.
 Acknowledgments

IRVIN YALOM:
I am grateful to Stanford University for providing the academic freedom and
library facilities necessary to accomplish this work. And I am grateful also to a
masterful mentor, Jerome Frank, for having introduced me to group therapy and
for having offered a model of integrity and dedication. Several people have
assisted us in this sixth revision by reading and critiquing some of its chapters: I
would like to thank Ruthellen Josselson, PhD; Meenakshi Denduluri, MD; and
my son, Ben Yalom, who masterfully edited several chapters. Lastly, I am
grateful to the members of my own leaderless therapists’ group, who continue to
reinforce my belief in the power and effectiveness of a therapeutic group.

MOLYN LESZCZ:
I am grateful to the University of Toronto Department of Psychiatry and Mount
Sinai Hospital for supporting me in completing this project. Toronto colleagues
who have contributed to this edition and facilitated its completion include Lesley
Wiesenfeld, MD; Joel Sadavoy, MD; Danny Silver, MD; Paula Ravitz, MD; Jan
Malat, MD; Roisin Byrne, MD; Smrita Grewal, MD; Robert Maunder, MD; and
Jon Hunter, MD. Group therapy colleagues whose input has been of great value
include Gary Burlingame, PhD; Greg Crosby, MSW; Haim Weinberg, PhD;
Martyn Whittingham, PhD; and Steinar Lorentzen, PhD. Liz Konigshaus
handled the painstaking task of compiling the many references and citations with
enormous efficiency and unyielding good nature. Jon Grosz made important
contributions to the editing process and Marie Maguire provided essential
administrative support. Benjamin, Talia, and Noah Leszcz, my children, and
Bonny Leszcz, my wife, contributed insight and encouragement throughout.

WE ARE BOTH VERY GRATEFUL TO LISA KAUFMAN AND KATHERINE Streckfus for their
very thoughtful and comprehensive editing of our text.
 -1-

The Therapeutic Factors

DOES GROUP THERAPY HELP CLIENTS? INDEED, IT DOES. A persuasive body of

outcome research has demonstrated consistently and unequivocally that group
therapy is a highly effective form of psychotherapy. Not only is it at least equal
to individual psychotherapy in its power to provide benefit, it also makes more
efficient use of mental health care resources.1 Yet, paradoxically, mental health
professional training programs have reduced training in group therapy. This is a
matter of great concern: we need to ensure high levels of quality in group
therapies if we are to achieve the impact that we desire—and that our clients
require.2 Throughout this text we will focus on the group factors and the
characteristics of leaders that contribute to therapeutic effectiveness.
How does group therapy help clients? A naive question, perhaps. But if we
can answer it with some measure of precision and certainty, we will have at our
disposal a central organizing principle with which to approach the most vexing
and controversial problems of psychotherapy. Once identified, the crucial
aspects of the process of change will constitute a rational basis for the therapist’s
selection of tactics and strategies to shape the group experience, maximizing its
potency with different clients and in different settings. Though group therapy
works, there is also great variability in the effectiveness of therapists.3
Understanding how best to implement these therapeutic processes is at the heart
of effective group therapy work. Fortunately, there is much to guide us from the
research evidence. Experience alone does not confer greater effectiveness. What
does? Deliberate practice, self-reflection, feedback on one’s practice, and the
wise use of an empathic and attuned therapeutic relationship.4
We suggest that therapeutic change is an enormously complex process that
occurs through an intricate interplay of human experiences, which we 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, we begin by describing and discussing these elemental
factors.
From our perspective, natural lines of cleavage divide the therapeutic
experience into eleven primary factors:

1. Instillation of hope
2. Universality
3. Imparting information
4. Altruism
5. The corrective recapitulation of the primary family group
6. Development of socializing techniques
7. Imitative behavior
8. Interpersonal learning
9. Group cohesiveness
10. Catharsis
11. Existential factors

In the rest of this chapter, we discuss the first seven factors. Interpersonal
learning and group cohesiveness are so important and complex that we address
them separately in the next two chapters. Existential factors are discussed in
Chapter 4, where they are best understood in the context of other material
presented there. Catharsis is intricately interwoven with other therapeutic factors
and will also be discussed in Chapter 4.
The distinctions among these factors can be arbitrary, and though we discuss
them singly, they are interdependent and neither occur nor function separately.
Moreover, these factors may represent different parts of the change process:
some factors (for example, interpersonal learning) act at the level of cognition;
others (for example, the development of socializing techniques) act at the level
of behavioral change; still others (for example, catharsis) act at the level of
emotion. Some (for example, cohesiveness) may be more accurately described as
both a therapeutic force itself and a precondition for change. Although the same
therapeutic factors operate in every type of therapy group, their interplay and
differential importance can vary widely from group to group. Furthermore,
because of individual differences, participants in the same group benefit from