Practice Guidelines for Group Psychotherapy

Therapeutic Factors and Therapeutic Mechanisms

Understanding mechanisms of action in group psychotherapy. Seasoned group therapists recognize that the success of individual group members is intimately linked to the overall health of the group-as-a-whole.  Indeed, a sizable portion of the clinical and empirical literature delineates therapeutic factors and mechanisms that have been linked with healthy well-functioning therapy groups. Mechanisms of action are interventions or therapeutic processes that are considered to be causal agents that mediate client improvement (Barron & Kenny, 1986).  These mechanisms take many forms, including experiential, behavioral and cognitive interventions, as well as processes central to the treatment itself, such as the therapeutic relationship.

            Debate about the existence and operation of unique therapeutic mechanisms of action for group therapy has a continuous, complex and contradictory history in the professional literature.  Some group therapists have argued that there are unique mechanisms of action intrinsic to all group therapies. An early voice noted that groups have unique properties of their own, which are different from the properties of their subgroups or of the individual members, and an understanding of these three units is critical in explaining the success or failure of small groups (Lewin, 1947). Indeed, later writers argued that a sound understanding of group dynamics was as important to a group therapist as knowledge regarding physiology is to a physician (Berne, 1966) Thus, the conventional clinical wisdom for decades has been that if one is going to offer treatment in a group, one must be aware of the intrinsic group mechanisms of action responsible for therapeutic change in members.

A contrasting perspective suggests that group theorists and clinicians have overemphasized group-specific mechanisms of action. Over 40 years ago, Slavson (1962) noted that the group psychotherapy literature often seems obsessed with attempts to appear original, contrasting itself with dyadic therapies.   Horwitz (1977) noted that some group writers and clinicians anthropomorphize the group so that it becomes the patient, leading the therapist to focus solely upon group-level interventions at the expense of individual members. 

Addressing this conundrum, Fuhriman and Burlingame (1990) reviewed the empirical literature to compare putative therapeutic mechanisms of action in group and individual treatments, reporting support for both positions. Table 1 reflects a consensually accepted list of therapeutic factors and a brief definition of each. 

Table 1.  The Therapeutic Factors (Yalom and Leszcz, 2005)

Specifically, the distinctiveness of some client characteristics, therapeutic interventions and therapeutic factors (examples include insight, catharsis, hope, reality testing) was not found when comparing major empirical reviews of the individual and group literature.  On the other hand, distinctive mechanisms of action emerged when multi-person relationship factors were considered.  Participating in a therapeutic venue comprised of multiple therapeutic relationships produced therapeutic factors that were unique to the group format (examples include vicarious learning, role flexibility, universality, altruism, interpersonal learning).  Empirical support for this proposition followed in a study (Holmes & Kivlighan, 2000) that found participants reported higher levels of relationship, climate and other-focused processes as responsible for change in group when contrasted with clients participating in individual treatment. 

Cohesion - a core mechanism of action. Of the described therapeutic factors (TFs), we consider the mechanism of cohesion to be most central – it is a therapeutic mechanism in its own and it facilitates the action of other TFs. There is growing consensus that cohesion is the best definition of the therapeutic relationship in group (Burlingame et al, 2002; Yalom & Leszcz, 2005).  In general, the therapeutic relationship is the ubiquitous mechanism of action that operates across all therapies (Martin et al, 2000).  It appears as important, if not more important, in explaining client improvement than the specific theoretical orientation practiced by the therapist (Norcross, 2001).  Indeed, in an extensive review, Wampold (2001) argued that common factors such as the therapeutic relationship may account for up to nine times greater impact on patient improvement than the specific mechanisms of action found in formal treatment protocols.

Cohesion defines the therapeutic relationship in group as comprising multiple alliances (member-to-member, member-to-group, and member-to-leader) that can be observed from three structural perspectives—intra-personal, intra-group and interpersonal (cf. Burlingame, et al., 2002).  Intrapersonal cohesion interventions focus on   members’ sense of belonging, acceptance, commitment and allegiance to their group (Bloch & Crouch, 1985; Yalom and Leszcz 2005) and have been directly related to client improvement.  For instance, members who report higher levels of relatedness, acceptance and support also report more symptomatic improvement (Mackenzie & Tschuschke, 1993). Intra-group definitions of cohesion focus on the group-level features such as attractiveness and compatibility felt by group-as-a-whole, mutual liking/trust, support, caring and commitment to “work” as a group.  This definition of cohesion has been linked to decreases in premature dropout (Mackenzie, 1987) and increased tenure (Yalom and Leszcz, 2005).  Finally, interpersonal definitions of cohesion focus on positive and engaging behavioral exchanges between members and have been linked to symptomatic improvement, especially if present in the early phases of group sessions (Budman et al., 1989).

Relation of cohesion to other therapeutic factors.  Cohesion has shown a linear and positive relationship with clinical improvement in nearly every published scientific report (Tschuschke and Dies, 1994).  Beyond this evidentiary base, it has also been linked to other important therapeutic processes.  High levels of cohesion have been related to higher self-disclosure which leads to more frequent and intense feedback (Fuehrer & Keys, 1988; Tschuschke & Dies, 1994). A positive relationship between cohesion and self-disclosure, member-to-member feedback and member-perceived support/caring has also been demonstrated (Braaten 1990).  In addition, early and high levels of engagement may buffer group members from becoming discouraged or alienated when subsequent conflict takes place during the “work” phases of the group (MacKenzie, 1994; Castonguay et al., 1998).  Notwithstanding the promising relations between cohesion and other important therapeutic factors, it must be acknowledged that most studies were correlational, making it difficult to determine causality.

            The number of articles, chapters and books about cohesion and its relationship to successful groups is so large (MacKenzie, 1987; Colijn et al., 1991) that attempts to derive evidence-based principles for its development and maintenance often seem daunting.  Table 2 offers a summary of a recent review of well-researched group dimensions that have been empirically linked to cohesion: group structure, verbal interaction, and emotional climate. 

                        Table 2   Evidence-based Principles Related to Cohesion (Burlingame et al 2002)

                                                      Use of Group Structure

Principle One.  Conduct pre-group preparation that sets treatment expectations, defines group rules, and instructs members in appropriate roles and skills needed for effective group participation and group cohesion.

Principle Two.  The group leader should establish clarity regarding group processes in early sessions since higher levels of early structure are predictive of higher levels of disclosure and cohesion later in the group.

Principle Three.  Composition requires clinical judgment to balance intrapersonal (individual member) and intragroup (amongst group members) considerations.

                                                          Verbal Interaction

Principle Four.  The leader modeling real-time observations, guiding effective interpersonal feedback, and maintaining a moderate level of control and affiliation may positively impact cohesion.

Principle Five.  The timing and delivery of feedback should be pivotal considerations for leaders as they facilitate the relationship-building process. These important considerations include the developmental stage of the group (for example challenging feedback is better received after the group has developed cohesiveness) and the differential readiness of individual members to receive feedback (members feel a sense of acceptance).

                                    Establishing and Maintaining an Emotional Climate

Principle Six.  The group leader’s presence not only affects the relationship with individual members but all group members as they vicariously experience the leader’s manner of relating.  Thus, the leader’s management of his or her own emotional presence in the service of others is critically important. For instance, a leader who handles interpersonal conflict effectively can provide a powerful positive model for the group-as-a-whole.

Principle Seven.  A primary focus of the group leader should be on facilitating group members’ emotional expression, the responsiveness of others to that expression, and the shared meaning derived from such expression. 

These dimensions reflect classes of interventions that have direct implications for clinical practice.  More specifically, group structure reflects interventions (e.g., pre-group role preparation, in-group exercises, and composition) designed to create specific member expectations or skills used in the group or group operations, including the establishment of group norms.  Verbal interaction reflects global principles of how a leader may want to model or facilitate member-to-member exchange over the course of the group. Emotional climate reflects interventions aimed at the entire group experience, with the aims of increasing safety and the work environment of the group.  Some of these dimensions are discussed herein and throughout this document, while others are better understood by consulting the original source of Table 2 (Burlingame et al., 2002). 

Assessment of therapeutic mechanisms in clinical practice.  For those clinicians who have an interest in tracking the therapeutic relationship in group psychotherapy, the American Group Psychotherapy Association (Burlingame et al., 2006) recently released a Core Battery of instruments to assist group clinicians in selecting members, tracking their individual improvement and assessing aspects of the therapeutic relationship.  This task force relied upon a recent study that sought to simplify the underlying dimensions used to describe the therapeutic relationship in group and evaluate the group process (Johnson et al., 2005).  Taken together, the measures address three components of the group therapy experience:  the positive relational bond, the positive working relationship, and negative factors that interfere with the bond or the work of therapy.  In addition, each component is addressed in terms of two perspectives:  the member’s relationship with the therapist and the member’s relationship with the group as a whole.  Table 3 indicates how each measure (or subscale of a measure) can be used to evaluate each of the six possible component-perspective combinations.

A critical and unique therapeutic mechanism of change in small group treatment relates to the interpersonal environment, often referred to as the social microcosm created when the leader and members join together in a therapeutic collective.  In addition to the therapist’s clinical sense, empirical assessment tools provide a structured approach to “taking the pulse” of the group interpersonal climate to ascertain what may be obstructing or facilitating interpersonal processes at a group level.  Leaders play a pivotal role in modeling and shaping this interpersonal environment (Fuhriman & Barlow, 1983) and are advised to pay careful attention to these particular mechanisms of change. It is particularly wise to focus upon the relational bond, working relationship/therapeutic alliance and negative factors.  Attention to these elements underscores the possibility that ruptures in the leader-member relationship may occur which can impede the work of therapy for a member or at times for the group as a whole, and even lead to the premature termination of members.  Therapeutic interventions intentionally targeting different structural units of the group (member-to-member, member-to-group, and member-to-leader) are encouraged as the therapist creates and/or maintains specific mechanisms of change.

Summary

1.         The group psychotherapy literature underscores the importance of leaders having an

understanding of mechanisms of change that are unique to group treatment (i.e. therapeutic factors)

so that group-level interventions are guided by theory and empirical evidence.

2.         Developing and maintaining a healthy group climate involves the therapist monitoring and

intervening at three structural levels of the group: intra-personal, intra-group and interpersonal.

3.         Group leaders can employ three classes of group-level interventions—structure, verbal

interaction and emotional climate—at strategic developmental stages of the group to develop and

maintain a health group climate.

4.         AGPA has developed the CORE BATTERY-R, (Burlingame et al., 2006) a set of evidence-based

measures to assist group leaders in monitoring the therapeutic climate of their groups and their clients’

progress with the aim of increasing the overall effectiveness of group psychotherapy.

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©2007 American Group Psychotherapy Association