Book Discussion: The Theory and Practice of Group Psychotherapy (Yalom and Leszcz)

I will post to my own thread to prevent the awful event of someone who is responsible for "monitoring" this forum and who has to fill some "quota" of responding to an un-responded thread, the horror of having to respond to this thread.

What I would like to introduce is a technique used by third grade teachers in book discussions.

I believe this was one of my children's third grade teachers. She taught my children and thereby me, as the parent who was guiding them in completing their homework assignments, that there were three basic ways of making connections between written material and increasing the relevance.

1. Text to Self Connection: This is when one reads the text and connects it to some personal life event.

2. Text to Text Connection: This is when one reads the text and connects it to something else in the text.

3. Text to World Connection: This is when one reads the text and connects it to something in the world.

The common factor, as you can see, is "reads the text." So this implies you have the text.

The text will cost you $59USD to download the Apple version online, and $67 or so USD to buy the hard copy. 

Also, being an author myself, I'm sensitive to copyright laws, so while I may quote sentences or very short portions of the text, I will do no more than that, because I respect the authors and their work. However, I will freely summarize the text and portions of it, in my own words, which are not as well-thought out as those of the authors, since part of the constraint I'm placing on myself in writing this thread is to make it unedited.

This is the 6th edition! The text has gone through permutations, most notably the last iteration, which includes information on online type support groups, much like 7 cups has tried to have online type support within its groups. There is also some fresh discussion about the impact of the Global Pandemic on people's mental health, and the subsequent rise in online type psychotherapy.

That's all for now!

Kindest regards,

Rose

My intent is definitely not to "recreate the Wheel." Obs has already posted a wonderful series of threads that discuss Elements of Group Psychotherapy.

Here's one of the threads, on Group Cohesiveness: https://www.7cups.com/forum/groupmod/General_2446/GroupSupportPrompt6ElementsofYalomGroupTherapyGroupCohesiveness_321888/

The only problem I noticed was that I was the only person to respond to the wonderful essay Obs wrote.

I wonder why that was. Does no one beside Obs and me care about "group cohesiveness?" Does no one understand what "group cohesiveness" means? Has no one here experienced "group cohesiveness." All these questions, and more, come to mind, when wondering why persons, who are inherently a part of a Group (the World) would not be interested in Group Cohesiveness?

In any case, as far as Group Cohesiveness goes, there is a whole Chapter and also a forum post, about this. And, in my mind, Group Cohesiveness, being one of the important stages a group goes through in its growth and development, is a very key and pivotal part of a group even functioning.

Those are my thoughts for now!

Signing off,

Rose

Because this online version of this book is organized so nicely, I went straight to Chapter 14: Online Psychotherapy Groups, which, it turns out, is the newest and also the shortest chapter in the book. 

I joined 7 cups prior to the Global Pandemic, when, apparently and for good reason, there was a sudden shift to online interaction. When I joined 7 cups, my primary entry point was the Member Sharing Circles, which I found very interesting because after research, I discovered that these were modeled after the Indigenous People's Sharing Councils, in which the entire membership would sit and pass a "talking stick." This way, each voice could be heard. I myself, at the point I joined 7 cups, was at a point where I was in need of ideas for parenting within a difficult situation for me. I found that the Sharing Circles provided the kind of affirmation and validation I needed, without any of the need to "drive to a group," or otherwise leave my house. Some of these advantages, convenience, being in the comfort of one's own environment, are captured in this chapter about Online Psychotherapy Groups, though there are some notable differences.

One difference is that the groups mentioned in the chapter mostly include visual communication of some sort, as in a screen with physical presence of people in a Zoom, Google Meet, Skype or another group format. This is different than the group chats on 7 cups, which are text based. Indeed, some of the problems of eye contact, reading social cues from others and so on are negatives to the online group experience. 

An interesting observation I gathered from this chapter is that online psychotherapy groups have the potential to be as "effective" as in person groups. "Effective" is such a loaded word. Let's unpack it a little bit. By "effective," the authors state that: "Brief, well-designed, well-planned VTC [sic] groups have reported outcomes comparable to in-person group therapy, notwithstanding some initial hesitation on the part of both clients and therapists." VTC = video-teleconferencing. "Participants have reported feeling less alone, better informed and well supported." "Group cohesion measures in VTC groups do appear to be less strong than in traditional face-to-face group therapy, but not to the degree that therapeutic outcomes are compromised." "It appears that VTC groups utilize all the familiar group therapeutic factors." (More on that later, as I'm reading this book out of sequence. We'll dive into the group therapeutic factors later. There are also some excellent threads written by A Silent Observer that provoke discussion on the forum about the particular group therapeutic factors. At some point, I may be able to gather these together and post them here, but at this point, suffice it to say, in the broadest strokes, there can be a therapeutic effect from online group support. This is promising. 

One sentences stood out at me: "Ethical guidelines require therapists to practice only in those areas in which they are competent." In addition to the technical aspects of putting together a group online, the group leader's "administrative tasks have always included responsibility for securing a safe, stable, secure environment for the group." Now, this also includes maintaining the platform and handling the technical aspects of the computer interface. 

In this chapter, there is much discussion about making the platform secure, password protected and HIPPAA compliant (in that medical information is protected). 

A point is made in this chapter that "for vulnerable clients who experience emotional dysregulation, some of the technical difficulties of VTC may be almost too much for them to contain. For example, having a group member's Internet [sic] connection fail in the midst of deep emotional work is particularly disturbing."

A discussion is also included in this chapter of some of the possible benefits of online work, such as convenience for the user, and active inquiry as being a possible compensating factor for some of the nonverbal communication that is missing when the platform is moved online.

In short, this was an interesting chapter, and I think, particularly relevant to 7 cups, as many of the discussion groups are online and the support is delivered through a text format.

Thank you for reading this. I look forward to sharing more as I dive into this book further!

Hi, Friends and Readers,

I will now report on a section of Chapter 13: Specialized Formats and Procedural Aids, more specifically, a subchapter entitled "Structured Exercises."

These words "Structured Exercises" denotes any activity in which a specific set of directions is given to a group, and then the group is expected to follow them.

I was thinking in reading this particularly of structured groups such as Sharing Circles, Discussions that have particular prompts posed by the Group Leader or Facilitator, and also Pop Up Question/Answer type Discussions and Games that are sometimes held in the Positivity Room or as Pop up times.

The point of structured exercises can be to speed up the development of the group by warming them up with procedures that bypass the normal developmental sequence of a group.

However, the primary findings from employing structured exercises is that while there may be an upside, in that the Facilitator may feel "empowered" because they are essentially in charge of the experience, that this sort of exercise takes away from one of the central tenets of any therapeutic group, and that is for the group members to be empowered to take charge of their own emotional growth and development, to dive into what may sometimes be difficult and emotionally charged material, and "reconnect clients to a sense of effectiveness, competence and social interaction." 

Examples are given in this section of some structured exercises, including deep breathing as a group, sharing based on a quick check in or emotional state prompt, and others.

An interesting conclusion found in research done on groups with structured exercises concluded, surprisingly to me, that the outcome was that the leaders of these groups were regarded more highly, because they are doing what leaders are supposed to do, but the individual members of these groups had "significantly less favorable outcomes than the members of groups with the fewest exercises." This suggests that structured exercises should be used judiciously, sparingly, if the outcome desired is for the group members to be improved.  In short, exercises may plunge a group quickly into greater expressivity but the group pays a price for speed, the group does not develop "a sense of autonomy and potency."

The suggestion by the end of this section was that, like many things in life, there is a middle ground. If the group is floundering and has nothing to say, then a quick structured exercise (much like an ice breaker) can be used to bring voices to the fore, but that excessive reliance on structured exercises has the effect of suppressing the natural developmental sequence of a group in functioning to promote insight and independence and empowerment among each individual member.

That's all for now!

Till next time, I remain, Truly Yours,

Rose

@CalmRosebud, thank you for sharing your thoughts here! I think Yalom is a great thinker and writer. He has some done some interesting work in the existential psychotherapy space that might be interesting and another book where he wrote with a client. It was interesting to see how much his client's view about what worked was different from his work.

I used this same text in training to become a psychologist many, many, many years ago! It is accessible and very good. I think the key points for me are instillation of hope, universalism (we are not alone in our struggles), catharsis, and vicarious learning. Seeing others go through something so we can learn.

I led groups in partial hospitalization, inpatient, and outpatient settings for year and think they are very powerful. It is actually how clinicians "scale" care in that group therapy is just as effective as individual therapy. And, bonus for me!, it builds community! On that note, you might also like a different drum by scott peck.

Thank you for sharing!

@CalmRosebud thank you for sharing many great reflections in this space - like Glen, I've also used this book as part of my training as a clinical psychologist. Groups have always fascinated me - the idea that individuals > peer support > community groups > flourishing safe spaces feels so empowering because everyone has a role without even realizing it at times. sort of like the Sharing Circles, where simply even reading can help us boost our days immensely.

I particularly enjoyed your reflection about online groups. 7 Cups has come very far in the past year in this regard. While our open groups show peer support well, special spaces like Sharing Circle or Exploration Garden highlight a culture of facilitation and holding space for one another -- the peer support lens will also fascinate you about how empowering it can be where everyone can facilitate. We have also had many versions of closed groups, modeling Yalom's key factors, called Huddles. Lately, we're running a self-esteem exploration in an "open" chat under Special Events and the reflections I've had over this week have been great.

I'm glad we have leaders like you who explore what groups can mean to pour power into what our community highlights as powerful: human connection.

Quoting Yalom in this book itself:

"There is no human deed or thought that lies fully outside the experience of other people"

@CalmRosebud

Thank you for sharing your insights and it is so powerful to read them. I believe the most effective type of therapists are the ones that tell their clients that they are the experts and they hold the key to unlocking doors and the therapist's role is to guide them to unlocking it. I think what I like particularly about this book is the approach of Yalom as he appears to be so insightful, warm, and compassionate. He really has taught me so much in my work and I am grateful to him! 

Group psychotherapy is truly remarkable as it provides validation within the shared experience and teaches people that they are not alone. It is great to see all cultures come together to really open up participants' minds into seeing different perspectives. I like how Yalom cultivates a shared safe space which is what we are continuously striving to do in Sharing Circles and Exploration Garden. 

Please keep them coming :) You may also like his other book The Gift of Therapy which is one of my favourites! He would truly immerse himself in the world of his patients and it is one of the key concepts which I always try to use in my own therapeutic work. 

Diving into Chapter 4: The Therapeutic Factors, an Integration

Friends and Readers,

It may seem weird to you, diving into Chapter 4 instead of covering Chapters 1-3 first, but have you met me?

Chapter 4 is all about Integration. Integration = Me.

Chapter 4 also offers up some spicy research studies on the interplay of the different factors, the Elements, that make for an “effective” group therapy. If you’ve followed along with The Silent Observer’s prompts on The Elements of Group Psychotherapy, you’ll recall that Yalom/Leszcz’s Therapeutic Factors include: Instillation of Hope, Universality, Imparting Information, Altruism, The Corrective Recapitulation of the Primary Family Group, Development of Socializing Techniques, and Imitative Behavior. In Chapter 2 there is a discussion of Interpersonal Learning, and in Chapter 3 a discussion of Group Cohesiveness. 

Don’t worry, I’ll get to my views on all of these chapters, but first let’s take a look at Chapter 4. 

Humor me. Integration is my “thing.”

 The interesting part of this chapter, from my perspective, is that the views of the participants are considered as well as the views of the therapist, or if one were to extrapolate the information to groups on 7 cups, it would be the Facilitator or the Host of the group. 

Let me be perfectly blunt.

The Facilitators here are Volunteers, not trained Psychotherapists. That is glaringly obvious more so at some times than at other times. But I will make it perfectly clear here that most people here do not have the very intensive, years long class schedule, clinical training and other input and practice, that licensed therapists have. However, that is not to say our group members lack expertise in general. In fact, I have noticed an intellectual bent to this group at times. Sometimes, I even feel like I’m in a Faculty Meeting.

I am also not suggesting that Facilitators or Group Leaders attain these qualifications. I, for example, am not going to go back to graduate school (again) to learn all this new information at this point. However, I am interested enough in being a high-quality Facilitator, that I picked up this book.

I want to “be better” at what I do, my little niche of Facilitating the Sharing Circles two times a week. I want my Facilitation to more closely replicate that of an actually Therapeutic Group. My dream is that a therapeutic group would be accessible and available, for free, to anyone, in any language. Our groups are currently run in English as the lingua franca, but of course, ideally, we would have groups that are therapeutic, in all languages where people have the need to share and to be heard and supported. A remarkable aspect of 7 cups is that this is already possible with the Listener:Member dyad. A person can ask for someone who is fluent in their language of comfort. This is great.

So, back to the group. 

“Presence is the hidden agent of help in all forms of therapy.”

This quote hit me strongly.

Why?

Because someone in the Sharing Circle will sometimes ask for their 7 minutes to share, but when their turn arrives, they are so emotional, or upset, they cannot put their thoughts into words. At those times, I have suggested that the rest of the people in the group either sit silently with the person who is sharing, or offer short supportive statements to the Sharer, affirmative statements of the Sharer’s worth as a part of this community. 

I do believe that the simple act of “presence” can have a powerful and positive effect on a person’s mental health.

Back to how this links to Existential Psychotherapy: 

“An important concept in existential therapy is that human beings may relate to the ultimate concerns of existence in one of two possible modes. On the one hand, we may suppress or ignore our situation in life and live in what Martin Heidegger termed a state of forgetfulness of being. In this everyday mode, we live in the world of things, in everyday diversions; we are absorbed in chatter, tranquilized, lost in the “they”; we are concerned only about the way things are. On the other hand, we may exist in a state of mindfulness of being, a state in which we marvel not at the way things are, but that they are. In this state, we are aware of being; we live authentically; we embrace our possibilities and limits; we are aware of our responsibility for our lives. (This state is captured well by Jean-Paul Sartre’s definition of responsibility: “To be responsible is to be the ‘uncontested author of…’”)”

This quote, to me, seems to capture the fact that we are, each of us, ultimately alone. We were born alone, we die alone. For much of our life, our souls operate alone. We truly are alone. When we are together in a group, we are each still individually alone. And to be “uncontested authors of” our lives (as Sartre so elegantly put it), we basically sometimes have to learn, from crying and silent sitting, to construct our halting and then stronger personal narratives.

I believe this is arena where the Sharing Circles are particularly powerful, in that (much like the early Councils of Indiginous Peoples), a person gets “the floor,” in the parlance of the Sharing Circle, they are the Sharers, and it’s their turn in the queue. The attention goes to them. 

I had a challenge just this morning with this very sort of attention. There was a lot of disruption prior to my arrival at the Sharing Circle, and suddenly there were many issues to be resolved. There was, for example, an ongoing discussion that was further muddled by one member misunderstanding who had said a certain thing, so it was very confusing for a few minutes while things got sorted. It really took much effort to just settle the group, post the guidelines for the room, and calm everyone so we could actually attend to the sharing in turn. There was a lot of cross talk, a lot of greeting. I found my limits were tested as to whether let things carry on and allow the group to work out the internal problems, or to gently remind of guidelines, offer respect to each person who spoke and move on with the shares. It is my intent, when I facilitate, to allow the groups to go through their developmental stages, since each group, going through these, does attain a sort of maturity, at which point the more experienced participants are able to guide the groups very well.

In any case, my point here is that being mindful of the group and how it’s developing, is not always an easy task, and is one that the facilitator or group leader must not take lightly. I believe this is one of the hurdles that was tackled with Huddles, where the group had a continuous membership. This would allow participants to establish a relationship with others in the group, and the group would be able to go through the normal developmental stages of a group, until finally everyone got to say goodbye.

With Sharing Circles, it’s difficult to see the development per se. When I joined 7 cups, four years ago, the Sharing Circles were only held at certain times during the day. The people who showed up at the start of the Sharing Circle got into the queue. Each person shared. The Sharing Circle was closed. Very soon after that, the Sharing Circles were “scaled up,” to 24/7, and alternated with Healthy Habits groups. The advantage to this early iteration, to me, is that the groups were facilitated. It was very rare for a group to be what is now called “Member Powered,” where Members run the Sharing Circle.

To have a therapeutic function, I do believe that the groups rather than being “open 24/7” should have beginnings and ends. Top of the hour seems rational. This is currently rarely done. Lou73 (@Lou73) tries valiantly to recruit new Hosts. They are one of the most sympathetic and kind persons I have ever met on 7 cups, and in fact, due to them, I became a Moderator. Lou has done more for 7 cups and specifically Sharing Circles, than they will ever realize. I have heard testimony from others as well, as to how supportive and kind Lou is as a Leader, how Lou guides Members along the tracks to becoming Listeners and then Room Supporters and then Mods. I also had this personal experience, that no matter what the ups and downs were through the rooms, over the four years I’ve been a part of 7 cups, Lou was always there for us.

All the recruitment information is in place for new Hosts/Facilitators. A Leaderboard is posted monthly.

All we need really are people to step up.

Why is it so difficult for people to step up?

I believe Lou73 hit on one major and positive factor, which is Competition. Yes, now Hosts will compete for Hero Host. (Or, Shero Hostess in my case lol.) This is a Brilliant Maneuver. I immediately wanted to be a Hero Host and even inserted into my script that not all Heroes wear Capes, some of us are bundled tightly in a Blanket. I absolutely LOVE this initiative and I hope many people will compete to host to receive this title.

Also, my hope is that more of the hours will be covered by someone who is: 1. Willing to stay through the hour, 2. Has received all the necessary training.

Exploration Garden opened up at the same time as Sharing Circles were still struggling to find hosts instead of working in conjunction and cooperation with Sharing Circles. Why do people go to Exploration Gardens to host? Because it’s not an entry point for new Members. Perhaps it’s easier that way. The sharing times are longer. Questions are allowed, something I personally dislike (questioning). The hosts don’t have to explain constantly what 7 cups is, and where is the new Member packet. Guidelines don’t have to be posted after every share. People who have found the Exploration Garden already know guidelines. But Exploration Gardens also seem to be open when they are hosted. Have I seen a Member Powered Exploration Garden yet? Have I looked? Perhaps this is a difficult topic right now. I will stay with Sharing Circles, which I know and love.

On the other hand, let’s move to the topic of Mental Health for the Masses.

What is it exactly that makes a Sharing Circle powerful and Effective? Effective is a loaded term. I wonder what that means to people. For most of the participants I have listened to within a Sharing Circle, the most important factor is “being heard.” The second most important factor is “being supported.” If my “street intelligence” is telling me this, then I wonder if we can simplify the Therapeutic Factors, which might be too much for most Host Facilitators to grasp initially, to simplify it to helping the Member “feel heard” and “feel supported.” To find out whether a Member “feels heard” and “feels supported,” I have asked a simple question at the end of a 7 minute share and then a 3 minute supportive comment: “Did you feel heard and supported during your share?”

This seems simple, but sometimes a Member will not necessarily “feel” heard, and a less experienced Facilitator Host might run to the next person in the queue without really listening. Also, what might happen is that some people are multi-tasking. They are running a day job, plus moderating another group, plus taking care of some other business (normal in this day and age), so during a person’s share, they are in and out, not truly present. Welcome to the world of online support. This is reality I am presenting to you, friends.

Let me move to another quote from Chapter 4:

“But there are certain jolting experiences (often referred to in the philosophical literature as “boundary experiences”) that effectively transport one into the mindfulness-of-being state.”

Yes, this quote resonated a great deal with me. My book (already published) is about end-of-life care of my aging parents. I frequently, during that time, wondered what I was doing, whether it was worthwhile, and why was I doing it because it might be near the end for them. Existential questions to be sure, and keenly interesting to me that the same term “boundaries” was used for the experiences that might be jolting: a medical diagnosis, an end- of-life diagnosis, cancer, sudden accidents leaving one the survivor. All these episodes lead to this feeling of an existential catastrophe, in the sense that one realizes one’s own mortality.

We are only on this road with others for a time and we are sharing this road, but we have to humble ourselves and decide what we will do with the rest of our lives. 

This brings me to the next quote I highlighted from Chapter 4, which is in reference to groups such as cancer diagnosis groups, or people receiving end of life diagnoses.

“It is asking a great deal of the therapist to join such a group, yet it would be hypocrisy not to join. The group does not consist of you (the therapist) and them (the dying); it is we who are dying together, we who are banding together in the face of our common condition. In my (IY) book The Gift of Therapy, I propose that the most accurate or felicitous term for the therapeutic relationship might be “fellow traveler.”

IY refers to Yalom, since the book was co-authored, the authors are very specific as to who had a particular experience.

Here is my last quote and comment from Chapter 4.

“Reviews of process and outcome research reveal that clients’ ratings of therapist engagement and empathy are more predictive of therapeutic success than therapists’ ratings of these same variables. These findings compel us to pay close attention to the client’s view of the most salient therapeutic factors. In research as in clinical work, we do well to heed the adage: Listen to the client.

To summarize: Therapists and their clients differ in their views about important therapeutic factors. Clients consistently emphasize the relationship and the personal, human qualities of the therapist, whereas therapists attribute their success to their techniques.”

To me, this quote was spot on, as the relationships created with individuals seem much more powerful than any technique one could employ. So, it matters what our Members think of our groups. It matters whether they feel “heard” and “supported,” whatever that means to them, especially within a group setting, where basically a talking stick is being passed around a circle. 

Each voice has resonance. Each voice has meaning. Each voice has power. 

We will get there, eventually. It will take a lot of work, but we will be able to get there with our groups. I believe in us. I believe in the groups. 

Signing off for now, I remain, yours truly,

With Love and Courage Always,

Rose

From Chapter 6: The Therapist, working in the here and now

Interesting quote, which would contradict the ban on what is called here “triangulation."

“A common myth that may need to be dispelled is that talking about a group member when that member is not present at a meeting is politically or socially incorrect. It is not “talking behind someone’s back,” and it will not lead to scapegoating, provided that the group adopts the practice of sharing the discussion with that member at the following meeting.”

Excerpt From

The Theory and Practice of Group Psychotherapy

Irvin D. Yalom & Molyn Leszcz

https://books.apple.com/us/book/the-theory-and-practice-of-group-psychotherapy/id1506563176

This material may be protected by copyright.

This quote implies that in fact the presence or absence of a particular person has impact on the group. However, it also implies a group that is rather continuous in membership, which, as we know, is not the case with many of the groups. Everyone does not know everyone, and there are many people who are outside of particular groups, for example, they only operate in the Listener:Member dyad, so there would be no opportunity for them to have experiences of each other.

However, I have seen discussions that are striving to be productive, eg. someone is discussing how another person affected them, and they are processing their feelings about it, being shut down as “gossip” or “triangulation.” I understand the fear of people scapegoating someone when they are talking about them behind their back, but isn’t this, in fact, how we as social beings operate? Don’t we plan surprise parties by talking with people quietly and secretly? Don’t we decide on having an intervention for someone when more than one person is concerned about their behaviors?

In fact, I just saw a movie last night “Starling,” which expertly approaches this very topic. People are concerned, and that’s why the protagonist in the movie seeks help, from an unlikely source, a vet who gave up psychotherapy. It’s a poignant movie. We care about each other and that’s why we even bother struggling and getting through things. 

Anyway, those are my thoughts for today. I will probably post more about chapter 6 soon, because the aspect of working in the here and now really does create some relevance for the groups such as Sharing Circle. What’s happening right now? How are we treating each other, talking with each other, validating each other in the present moment? All of these questions and their answers are fuel for further discussion. A rich field for discovery indeed.

@CalmRosebud   Please keep sharing whatever you find interesting in this book, let us grow together, sending love