The Theory and Practice of Group Psychotherapy (102 page)

One team of researchers adapted a loneliness-reducing face-to-face cognitive-behavioral group intervention
⁹⁹
to a synchronous, therapist-led support group that met for twelve two-hour sessions. Significant reductions of loneliness in the nineteen subjects were achieved and sustained at four-month follow-up. The small sample size limits the validity of the conclusions, but the researchers demonstrated the feasibility of applying a specific intervention designed for a face-to-face group to an online format.

“Student Bodies” is an Internet support group that is part of a large public health intervention and research enterprise. It is essentially an asynchronous moderated Internet support group intended to prevent eating disorders in adolescent and young women.
¹⁰⁰
On a secure Web site, it offers participants psychoeducation about eating disorders and encourages them to journal online about their body, eating, and their responses to the psychoeducation. They may also post messages through the moderator about personal challenges and successes in the modification of disordered thinking about eating. This intervention resulted in improvements in weight, body image concerns, and eating attitudes and behaviors.
¹⁰¹

In a study of sixty college students, researchers added to the “Student Bodies” program an eight-session, moderated,
synchronous
(that is, meeting in real time) Internet support group component. They found that the synchronous online group format expanded client gains.
¹⁰²

A study of 103 participants in an asynchronous, open-ended peer Internet support group for depression found that many of the members of the group valued it highly, spending at least five hours online over the preceding two weeks. More than 80 percent continued to receive face-to-face care, viewing the online group as a supportive adjunct, not a substitute for traditional care.
¹⁰³
One participant’s account of her experience describes many of the unique benefits of the Internet support group:

I find online message boards to be a very supportive community in the absence of a “real” community support group. I am more likely to interact with the online community than I am with people face to face. This allows me to be honest and open about what is really going on with me. There are lots of shame and self-esteem issues involved in depression, and the anonymity of the online message board is very effective in relieving some of the anxiety associated with “group therapy” or even individual therapy. I am not stating that it is a replacement for professional assistance, but it has been very supportive and helped motivate me to be more active in my own recovery program.
¹⁰⁴

CHESS (Comprehensive Health Enhancement Support System), a sophisticated Internet group program developed at the University of Wisconsin, has provided support for people with AIDS, cancer, and for caregivers of Alzheimer’s patients. The group program consists of three elements. First, it provides relevant information and resources through online access to experts and question-and-answer sessions. Second, a facilitator-mediated discussion group offers an opportunity for members to obtain social support by sharing their personal story and reacting to the stories of the other members. Third, it helps clients formulate and then implement an action plan for constructive change, such as scheduling time away from caregiving for self-care. Over many years, thousands of participants with a range of medical concerns have completed questionnaires about the impact of these interventions. Reported benefits include briefer hospitalizations, improved communication with health care providers, and an increased sense of personal empowerment.†
¹⁰⁵

The results of two different Internet support group approaches for women with breast cancer have been reported. One program evaluated seventy-two women with primary breast cancer in a twelve-week, moderated, Web-based asynchronous group, structured according to the supportive-expressive group therapy model described earlier in this chapter and run in partnership with Bosom Buddies, a peer support network for women with cancer. The groups reduced depression and cancerrelated stress scores. Women typically logged on three times a week and used this group experience to launch an informal support network that has continued long after the twelve-week treatment ended.
¹⁰⁶

The second program, a synchronous, sixteen-session group led by trained facilitators from the Wellness Community (an international, not-for-profit organization supporting the medically ill) for thirty-two women with primary breast cancer, also reduced depression and reactions to pain.
¹⁰⁷

All Internet support groups develop their own specific set of norms and dynamics. An analysis of text postings in groups for women with breast cancer demonstrated that groups with a trained moderator were more likely to express distressing emotions, which has the effect of reducing depression.
¹⁰⁸
The moderator’s skill in activating, containing, and exploring strong emotion appears to be as important in online support groups as in face-to-face groups.
¹⁰⁹

We are just at the beginning of the use of electronic technology in the provision of mental health care. If it does turn out to help us connect meaningfully, it would be a pleasant and welcome surprise—an all-too-rare instance of technology increasing rather than decreasing human engagement.

Chapter 16

GROUP THERAPY: ANCESTORS AND COUSINS

D
uring the 1960s and 1970s, the encounter group phenomenon, a heady, robust social movement, swept through the nation. Huge numbers of individuals participated in small groups sometimes described as “therapy group for normals.” Today whenever I mention encounter groups to students I am greeted by quizzical looks that ask, “What’s that?” Although encounter groups are largely a thing of the past, their influence on group therapy practice continues today.

There are several reasons the contemporary group therapist should have, at the very least, some passing knowledge of them.

1. First, as I discuss in chapter seventeen, the proper training of the group therapist must include some personal group experience. Few training programs offer a traditional therapy group for trainees; instead they provide some variant of an encounter group, today often labeled a “process group.” (For the moment, I refer to all experiential groups as encounter groups, but shortly I will define terms more precisely.) Thus, many group therapists enter the field through the portals of the encounter group.

2. Secondly, the form of contemporary group therapy has been vastly influenced by the encounter group. No historical account of the development and evolution of group therapy is complete without a description of the cross-fertilization between the therapy and the encounter traditions.

3. Lastly, and this may seem surprising, the encounter group, or at least the tradition from which it emerged, has been responsible for developing the best, and the most sophisticated, small group research technology. In comparison, the early group therapy research was crude and unimaginative; much of the empirical research I have cited throughout this text has its roots in the encounter group tradition.

In this chapter I provide a lean overview of the encounter group and then expand on these three points. Readers who would like more information about the rise, efflorescence, and decline of this curious social movement may read a more detailed account (the chapter on encounter groups from the previous edition of this text) on my Web site,
www.yalom.com
.

WHAT IS AN ENCOUNTER GROUP?

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

Although the nominal plumage is dazzling and diverse, all these experiential groups have several common elements. They range in size from eight to twenty members—large enough to encourage face-to-face interaction, yet small enough to permit all members to interact. The groups are time limited and are often compressed into hours or days. They are referred to as “experiential groups” because they focus to a large extent on their own experience, that is, the here-and-now. They transcend etiquette and encourage the doffing of traditional social facades; they value interpersonal honesty, exploration, confrontation, heightened emotional expressiveness, and self-disclosure. The group goals are often vague: occasionally they stress merely the provision of an experience—joy, entertainment, being turned on—but more often they implicitly or explicitly strive for some
change
—in behavior, in attitudes, in values, in lifestyle, in self-actualization, in one’s relationship to others, to the environment, to one’s own body. The participants are considered “seekers” and “normals,” not “patients” or “clients”; the experience is considered not therapy but “growth.”

ANTECEDENTS AND EVOLUTION OF THE ENCOUNTER GROUP

The term “encounter group” became popular in the mid-1960s, but the experiential group had already existed for twenty years and was most commonly referred to as a “T-group”—“T” for training (in human relations).

The first T-group, the ancestral experiential group, was held in 1946. Here is the story of its birth.
¹
The State of Connecticut had passed the Fair Employment Practices Act and asked Kurt Lewin, a prominent social psychologist, to train leaders who could deal effectively with tensions among ethnic groups and thus help to change the racial attitudes of the public. Kurt Lewin organized a workshop that consisted of groups of ten members each. These groups were led in the traditional manner of the day; they were basically discussion groups and analyzed “back-home” problems presented by the group members.

Lewin, a strong believer in the dictum “
No research without action; no action without research,”
assigned research observers to record and code the behavioral interactions of each of the small groups. During evening meetings, the group leaders and the research observers met and pooled their observations of leaders, members, and group process. Soon some participants learned of these evening meetings and asked permission to attend. This was a radical request; the staff hesitated: not only were they reluctant to reveal their own inadequacies, but they were uncertain about how participants would be affected by hearing their behavior discussed openly.

Finally they decided to permit members to observe the evening meetings on a trial basis. Observers who have written about this experience report that the effect on both participants and staff was “electric.”
²
There was something galvanizing about witnessing an in-depth discussion of one’s own behavior. The format of the evening meetings was widened to permit the participants to respond to the observations and soon all parties were involved in the analysis and interpretation of their interaction. Before long, all the participants were attending the evening meetings, which often ran as long as three hours. There was widespread agreement that the meetings offered participants a new and rich understanding of their own behavior.

The staff immediately realized that they had, somewhat serendipitously, discovered a powerful technique of human relations education—
experiential learning
. Group members learn most effectively by studying the interaction of the network in which they themselves are enmeshed. (By now the reader will have recognized the roots of the “here-and-now” in contemporary group therapy.) The staff discovered that members profit enormously by being confronted, in an objective manner, with on-thespot observations of their own behavior and its effects on others. These observations instruct members about their interpersonal styles, the responses of others to them, and about group behavior in general.

From this beginning, research was woven into the fabric of the T-group—not only the formal research conducted but also
a research attitude
on the part of the leader, who collaborates with the group members in a research inquiry designed to enable participants to experience, understand, and change their behavior. This research attitude, together with the concept of the T-group as a technique of education, gradually changed during the 1950s and 1960s, as Rogerian and Freudian clinicians began participating in human relations laboratory training and chose to focus ever more heavily on interpersonal interaction and personal change.

These clinically oriented leaders heavily emphasized the here-and-now and discouraged discussion of any outside material, including theory, sociological and educational reflections, or any “there-and-then” material, including “back-home” current problems or past personal history. I attended and led encounter groups in the 1960s in which leaders customarily began the group with only one request, “Let’s try to keep all our comments in the here-and-now.” It sounds impossible, and yet it worked well. Sometimes there was a long initial silence, and then members might begin describing their different feelings about the silence. Or often there were differential responses to the leader’s request—anxiety, puzzlement, impatience, or irritation. These different responses to either the silence or the leader’s instructions were all that was needed to launch the group, and in a short time it would be up and running.

In addition to the here-and-now focus, the T-group made many other major technical innovations destined to exert much influence on the psychotherapy group. Let’s examine four particularly important contributions: feedback, observant participation, unfreezing, and cognitive aids.