Build upon the topic selected in the Psychoeducational Group Plan Assignment to focus on developing a psychotherapy group. The first step in this process is

EDCO 711

Psychotherapy Group Advertisement Assignment Instructions

Overview 

This assignment offers an opportunity to transition from a psychoeducational group to a psychotherapy group focus. The task is to create a recruitment flyer for your psychotherapy group, aimed at attracting appropriate participants. This flyer should reflect a professional tone, clear communication, and adherence to ethical considerations in group therapy recruitment.

Instructions 

Students will build upon the topic selected in Psychoeducational Group Plan Assignment as the course shifts to focus on developing a psychotherapy group. The first step in this process is to create a recruitment flyer that effectively communicates the purpose and structure of the group while attracting suitable members. The flyer must include the following components:

1. Brief Description of the Group's Topic Provide a concise yet compelling summary of the psychotherapy group's topic, highlighting its relevance and importance. This section should clearly convey the purpose of the group and why potential participants would benefit from joining. Infusion of scholarly evidence is required when describing the group’s topic and importance, with an emphasis on synthesizing the references utilized.

2. Participant Inclusion/Exclusion Criteria Specify the criteria for participation, including both inclusion and exclusion guidelines. This ensures that the group composition aligns with the therapeutic goals and ethical guidelines of group therapy.

3. Type of Group Indicate whether the group will be open or closed, homogeneous or heterogeneous. This information is critical in helping potential participants understand the group’s dynamics and structure.

4. Setting and Structure Outline the logistical aspects of the group, including the physical or virtual setting, the frequency of meetings, and the duration of the group. These details are essential for participants to understand the commitment involved.

5. Pre-Group Meetings or Preparation Include any information about any pre-group meetings or other preparatory steps required for participants. This helps to ensure that group members are adequately prepared for the therapy process.

Formatting and Design The flyer should be visually appealing, clear, and professional with proper credit given to any graphics or resources used. Ensure the information is well-organized, concise, and easy to read. Due to the brief nature of an advertisement, no direct quotes should be utilized. The flyer should be one page in length, at lest one reference must be used to describe the group’s topic.

Assessment Your assignment will be evaluated based on the clarity, professionalism, and effectiveness of the advertisement in communicating essential information to potential group members.

Note: The assignment will be checked for originality via the Turnitin plagiarism tool.

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Read: Yalom: Chapters 3, 7 – 9

Yalom, I. D., Leszcz, M. (2020-12-01). The Theory and Practice of Group Psychotherapy, 6th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9781541617568

Chapters 3

Group Cohesiveness

IN THIS CHAPTER WE EXAMINE THE PROPERTIES OF COHESIVENESS, the considerable evidence for group cohesiveness as a therapeutic factor, and the various pathways through which cohesiveness exerts its therapeutic influence.

What is cohesiveness and how does it influence therapeutic outcome? The short answer is that cohesiveness is the group therapy analogue to the relationship in individual therapy. First, keep in mind that a vast body of research on individual psychotherapy demonstrates that a good therapist-client relationship is essential for a positive outcome. The link between the therapeutic alliance and outcome is one of the most reliable research findings in our field.1 Is it also true that a good therapy relationship is essential in group therapy? Here again, the literature leaves little doubt that “relationship” is germane to positive outcome in group therapy.2 But relationship in group therapy is a far more complex concept than relationship in individual therapy. After all, there are only two people in the individual therapy relationship, whereas a number of individuals, generally six to ten, work together in group therapy. Hence it is insufficient to say that a good relationship is necessary for successful group therapy—we must also specify which relationship: The relationship between the client and the group therapist (or therapists, if there are co-leaders)? Or between the group member and other members? Or perhaps even between the individual and the “group” taken as a whole? In other words, there are intrapersonal, interpersonal, and group variables to consider as well.3

Over the past sixty years, a vast number of controlled studies of psychotherapy outcome have demonstrated that the average person who receives psychotherapy is significantly improved and that the outcome from group therapy is virtually identical to that of individual therapy.4 Furthermore, there is evidence that certain clients may obtain greater benefit from group therapy than from other approaches, particularly clients dealing with stigma or social isolation and those seeking new coping skills.5

The evidence supporting the effectiveness of group psychotherapy is so compelling that it prompts us to direct our attention toward another question: What are the necessary conditions for effective psychotherapy? After all, not all psychotherapy is successful. In fact, there is evidence that treatment may be for better or for worse—although most therapists help their clients, some therapists make some clients worse.6 Why? What are the characteristics of a successful therapist? Although many factors are involved, effective therapists are empathically attuned to their clients and are able to provide an understandable, culturally resonant explanation of distress and its treatment that in turn builds the client’s self-efficacy.7 Research evidence overwhelmingly supports the conclusion that successful therapy—indeed, even successful pharmacotherapy treatment—is mediated by a relationship between treater and client that is characterized by agreement on the goals and tasks of treatment and marked by trust, warmth, empathic understanding, and acceptance.8

Although a positive therapeutic alliance is common to all effective treatments, it is by no means easily or routinely established. Extensive therapy research has focused on the nature of the therapeutic alliance and the specific interventions required to achieve, maintain, and repair the alliance when it gets strained or frayed.9

Is the quality of the relationship related to the therapist’s theoretical orientation? The evidence says no. Effective clinicians from different schools (psychodynamic, psychoanalytic, emotion-focused, humanistic, interpersonal, cognitive-behavioral) resemble one another (and differ from nonexperts in their own school) in their conception of the ideal therapeutic relationship and in the relationship they themselves establish with their clients.10

Note that the engaged, cohesive therapeutic relationship is necessary in all effective psychotherapies, even in the so-called mechanistic approaches—cognitive, behavioral, or systems-oriented forms of psychotherapy.11 One of the first large comparative psychotherapy trials, the National Institute of Mental Health’s (NIMH) Treatment of Depression Collaborative Research Program, concluded that successful cognitive-behavioral therapy or interpersonal therapy required “the presence of a positive attachment to a benevolent, supportive, and reassuring authority figure.”12 Research has shown that the client-therapist bond and the technical elements of cognitive therapy are synergistic: a strong and positive bond in itself disconfirms depressive beliefs and facilitates the work of modifying cognitive distortions. The absence of a positive bond renders technical interventions ineffective or even harmful.13 The experience the client has of the treater is of enormous importance and is a good predictor of outcome.14 And this experience emerges in large part from the therapist’s actions and use of self.15 More and more, these core therapist relationship capacities are being recognized as key foci in training programs.16

As noted, relationship plays an equally critical role in group psychotherapy. But the group therapy analogue of the client-therapist relationship in individual therapy must be a broader concept, encompassing the individual’s relationship to the group therapist, to the other group members, and to the group as a whole. In this text we refer to all of these relationships with the term “group cohesiveness.” Cohesiveness is a widely researched basic property of groups that has been explored in several hundred research articles, reviews, and meta-analytic studies synthesizing huge data pools.17 Unfortunately, there is little cohesion in the cohesion literature, which suffers from the lack of replication studies and the use of different definitions, scales, subjects, and rater perspectives.18

In general, however, the studies agree that groups differ from one another in the amount of “groupness” present. Those with a greater sense of solidarity, or “we-ness,” value the group more highly and have higher attendance, participation, and mutual support. Nonetheless, it is difficult to formulate a precise definition. A thoughtful review concluded that cohesiveness “is like dignity: everyone can recognize it but apparently no one can describe it, much less measure it.”19 The problem is that cohesiveness refers to overlapping dimensions. On the one hand, there is a group phenomenon—the total esprit de corps; on the other hand, there is the individual member cohesiveness (or, more strictly, the individual’s attraction to the group and to the leader).20 Furthermore, both the client’s emotional experience and the sense of task effectiveness in the group contribute to cohesion.21

In this book, we define cohesiveness as the attractiveness of a group for its members.22 Members of a cohesive group feel warmth and comfort in the group and a sense of belonging; they value the group and feel they are valued, accepted, and supported by other members.23

Esprit de corps and individual cohesiveness are interdependent, and group cohesiveness is sometimes computed simply by summing the individual members’ level of attraction to the group. Newer, more sophisticated methods of measuring group cohesiveness, such as the Group Questionnaire (GQ) developed by Gary Burlingame and colleagues, are gaining prominence and promise a more valid and reliable assessment of group cohesion.i

The more we examine cohesiveness, the more complexity we encounter. For example, we now know that each client’s view of cohesiveness is impacted by the group cohesiveness other members feel. Group cohesiveness is generally considered as a summation of the individual members’ sense of belonging, but we have also learned that group members are differentially attracted to the group—personality, interpersonal patterns, and attachment style all play a large role.24 Furthermore, while cohesiveness is not fixed but instead fluctuates greatly during the course of the group, we know that early cohesion is essential in setting the stage for the more challenging work to follow.25 Research has also differentiated between the members’ sense of belonging and their appraisal of how well the entire group is working. It is not uncommon for an individual to feel “that this group works well, but I’m not part of it.”26 It is also possible for members (for example, eating disorder clients) to value the interaction and bonding in the group yet be fundamentally opposed to the group goal.

Before leaving the matter of definition, we must point out that group cohesiveness is not only a potent therapeutic force in its own right; it is a precondition for other therapeutic factors to function optimally. When, in individual therapy, we say that it is the relationship that heals, we do not mean that love or loving acceptance is enough; we mean that an ideal therapist-client relationship creates conditions in which the necessary risk-taking, self-disclosure, catharsis, and intrapersonal and interpersonal exploration may unfold. It is the same for group therapy: Cohesiveness is necessary for other group therapeutic factors to operate.

THE IMPORTANCE OF GROUP COHESIVENESS

Although we discuss the therapeutic factors separately, they are, to a great degree, interdependent. Catharsis and universality, for example, are not complete processes. It is not the sheer process of ventilation, or the discovery that others have problems similar to one’s own, and the ensuing disconfirmation of one’s wretched uniqueness, that are important: it is the affective sharing of one’s inner world and then the acceptance by others that seems of paramount importance. To be accepted by others challenges the client’s belief that he or she is basically repugnant, unacceptable, or unlovable. The need for belonging is innate in all of us. Both affiliation within the group and attachment in the individual setting address this need.27 Therapy groups generate a positive, self-reinforcing loop: trust–self-disclosure–empathy–acceptance–trust.28 If norms of nonjudgmental acceptance and inclusiveness are established early and the member adheres to the group’s procedural norms, a member will be accepted by the group regardless of past transgressions, social failings, alternative lifestyles, or substance abuse or a history of prostitution or criminal offenses.

For the most part, the flawed interpersonal skills of our clients have limited their opportunities for effective sharing in either one-to-one relationships or groups. Not infrequently, the therapy group offers isolated clients their only deeply human contact. After just a few sessions, members often have a stronger sense of being at home in the group than anywhere else. Later, even years afterward, when most other recollections of the group have faded from memory, they may still remember this warm sense of belonging and acceptance.

As one successful client looking back over two and a half years of group therapy put it, “the most important thing in it was just having a group there, people that I could always talk to, that wouldn’t walk out on me. There was so much caring and hating and loving in the group, and I was a part of it. I’m better now and have my own life, but it’s sad to think that the group’s not there anymore.”

Furthermore, group members see that they are not just passive beneficiaries of group cohesion; they also generate that cohesion and create durable relationships—perhaps for the first time in their lives. One group member commented that he had always attributed his aloneness to some unidentified, intractable, and repugnant character failing. It was only after he stopped missing meetings regularly because of his discouragement and sense of futility that he discovered the part he played in his aloneness: that relationships do not inevitably wither. Instead, his previous relationships had been doomed by his choice to neglect them.

Some individuals internalize the group and repopulate their inner world. Years later, one client noted, “It’s as though my old group is sitting on my shoulder, watching me. I’m forever asking, What would the group say about this or that?” Often therapeutic changes persist and are consolidated because, even years later, the members don’t want to let the group down.29

Many of our clients have an impoverished history of social connection and have never felt valuable and integral to a group. For these individuals, a positive group experience may in itself be healing. Belonging in the group raises self-esteem and meets members’ dependency needs, but in ways that also foster responsibility and autonomy.30

Still, for some members, belonging can generate feelings of psychological regression: belonging can be frightening because it evokes fear of loss of self and of relinquishing personal autonomy.31 More typically, however, members of a therapy group come to mean a great deal to one another. The therapy group, at first perceived as an artificial construct that does not matter, may come to matter very much over time as members share their innermost thoughts. We have known groups whose members support one another through times of severe depression, through manic episodes, and through divorce, abortion, suicide, and sexual abuse, or even through the here-and-now feelings of betrayal within the group when two group members violate the group norms through a sexual encounter.

Even the most unlikely clients can form cohesive groups, as shown in a recent study of group therapy for marginalized intravenous drug users from the inner city with hepatitis C.32 We have seen a group actually carry one of its members to the hospital, and many groups mourning the death of a member. We have seen members of cancer support groups deliver eulogies at the funerals of other members. Relationships are often cemented by emotionally intense shared experiences. How many relationships in life are so richly layered?

Benefits of Group Cohesiveness: Evidence

Empirical evidence for the impact of group cohesiveness may not be as extensive or as systematic as research documenting the importance of relationship in individual psychotherapy, but is still very clear and relevant.33 Studying the effect of cohesiveness is more complex34 because it involves variables closely related to cohesion such as group climate (the degree of engagement, avoidance, and conflict in the group),35 therapist empathy,36 and alliance (the member-therapist relationship).37 The Group Questionnaire devised by Burlingame and colleagues synthesizes all these dimensions.38 The results of the research from all these perspectives, however, point to the same conclusion: Relationship is at the heart of effective group therapy.39

Group cohesion is no less important in the era of third-party oversight than it was in the past. In fact, the contemporary group therapist has an even larger responsibility to safeguard the therapeutic relationship in the face of imposed restrictions and intrusions from bureaucratic forces.40

We now turn to a broad overview of contemporary research and literature on cohesion. It highlights many of the approaches group researchers have used to evaluate and understand group cohesion and its clinical impact. (Readers who are less interested in research methodology and more interested in its direct clinical relevance may wish to proceed directly to the summary section.)

• In an early study of former group psychotherapy clients, investigators found that more than half considered mutual support the primary mode of help in group therapy. Clients who perceived their group as cohesive attended more sessions, experienced more social contact with other members, and felt that the group had been therapeutic. Improved clients were significantly more likely to have felt accepted by the other members and to mention particular individuals when queried about their group experience.41

• In 1970, I (IY) reported a study in which successful group therapy clients were asked to look back over their experience and to rate, in order of effectiveness, the series of therapeutic factors I describe in this book.42 Since that time, a vast number of studies using analogous designs have generated considerable dataon clients’ views of those aspects of group therapy that have been most useful. We will examine these results in depth in the next chapter; for now, it is sufficient to note that there is a strong consensus that clients regard group cohesiveness as an extremely important determinant of successful group therapy.

• In a six-month study of two long-term therapy groups, observers rated the process of each group session by scoring each member on five variables: acceptance, activity, sensitivity, abreaction (catharsis), and improvement.43 Weekly self-ratings were also obtained from each member. Both the research raters and group members considered “acceptance” to be the variable most strongly related to improvement.

• Similar conclusions were reached in a study of forty-seven clients in twelve psychotherapy groups. Members’ self-perceived personality change correlated significantly with both their feelings of involvement in the group and their assessment of total group cohesiveness.44

• My colleagues and I (IY) evaluated the one-year outcome of all forty clients who had started therapy in five outpatient groups.45 Outcome was then correlated with variables measured in the first three months of therapy. Positive outcome in therapy significantly correlated with only two predictor variables: group cohesiveness and general popularity—that is, clients who, early in the course of therapy, were most attracted to the group (high cohesiveness), and who were rated as more popular by the other group members at the sixth and twelfth weeks, had a better therapy outcome at the fiftieth week.46 The popularity finding, which in this study correlated even more positively with outcome than cohesiveness did, is, as we shall discuss shortly, relevant to group cohesiveness and sheds light on the mechanism through which group cohesiveness mediates change.

• The same findings emerge in more structured groups. A study of fifty-one clients who attended ten sessions of behavioral group therapy demonstrated that “attraction to the group” correlated significantly with improved self-esteem and inversely correlated with the group dropout rate.47

• The quality of intermember relationships has also been well documented as an essential ingredient in experiential groups intended to teach participants about group dynamics, such as T-groups and process groups. A rigorously designed study found a significant relationship between the quality of intermember relationships and outcome in a T-group of eleven subjects who met twice a week for a total of sixty-four hours.48 The members who entered into the most two-person mutually therapeutic relationships showed the most improvement during the course of the group.49 Furthermore, the perceived relationship with the group leader was unrelated to the extent of change.

• My colleagues Morton Lieberman and Matthew Miles and I (IY) conducted a study of 210 subjects in eighteen encounter groups encompassing ten ideological schools that reflected the field at the time. (These were gestalt, transactional analysis, T-groups, Synanon, personal growth, Esalen, psychoanalytic, marathon, psychodrama, and encounter tape, a group led by tape-recorded instructions.)50 Cohesiveness was assessed in several ways and reliably correlated with outcome.51 The results indicated that attraction to the group is indeed a powerful determinant of outcome. All methods of determining cohesiveness demonstrated a positive correlation between cohesiveness and outcome. A member who experienced little sense of belonging or attraction to the group, even measured early in the course of the sessions, was unlikely to benefit from the group and, in fact, was likely to have a negative outcome. Furthermore, the groups with the higher overall levels of cohesiveness had a significantly better total outcome than groups with low cohesiveness.

• Another large study (N = 393) of experiential training groups yielded a strong relationship between affiliativeness (a construct that overlaps considerably with cohesion) and outcome.52

• Roy MacKenzie and Volker Tschuschke, studying twenty clients in long-term inpatient groups, differentiated members’ personal “emotional relatedness to the group” from their appraisal of “group work” as a whole. The individual’s personal sense of belonging correlated with future outcome, whereas the total group work scales did not.53

• Simon Budman and his colleagues developed a scale to measure cohesiveness via observations by trained raters of videotaped group sessions. They studied fifteen therapy groups and found greater reductions in psychiatric symptoms and improvement in self-esteem in the most cohesively functioning groups. Group cohesion that was evident early—within the first thirty minutes of each session—predicted better outcomes.54

• A number of other studies have examined the role of the relationship between the client and the group leader in group therapy. Elsa Marziali and colleagues examined group cohesion and the client–group leader relationship in a highly structured thirty-session manualized interpersonal therapy group of clients with borderline personality disorder.55 Cohesion and member-leader relationship correlated strongly, supporting Budman’s findings, and both positively correlated with outcome.56 However, the member–group leader relationship measure was a more powerful predictor of outcome. The relationship between client and therapist may be particularly important for clients who are vulnerable or who have volatile interpersonal relationships, because for them the therapist serves an important containing and supportive function.

• Anthony Joyce and colleagues explored the experience of clients treated in brief group therapy for complicated loss and bereavement. They reported that the client’s strength of alliance to the therapist predicted a better outcome and showed a higher correlation with outcome than did group cohesion. This underscores the importance of looking at the individual client’s experience and not only the group’s cohesiveness, particularly in brief groups where an early positive start is essential.57

• Group therapy outcomes for social phobia were significantly better at both the end of treatment and at follow-up when clients reported higher engagement scores on the Group Climate Questionnaire developed by K. R. MacKenzie. Higher avoidance scores, in contrast, correlated with greater client distress. High conflict was also problematic and may be a sign of group trouble, rather than a necessary phase of group development that group leaders should casually accept.58

In a study of a short-term, structured, cognitive-behavioral therapy group for social phobia, the relationship with the therapist deepened over the twelve weeks of treatment and correlated positively with outcome, but group cohesion was static and not related to outcome.59 In this study the group was a setting for therapy and not an agent of therapy. Intermember bonds were not cultivated by the study therapists, leading the authors to conclude that in highly structured groups, what might matter most is the client-therapist collaboration around the therapy tasks.60

• A study of thirty-four clients with depression and social isolation treated in a twelve-session interactional problem-solving group reported that clients who described experiencing warmth and positive regard from the group leader had better therapy outcomes. The opposite also held true. Negative therapy outcomes were associated with negative client–group leader relationships. This correlative study does not address cause and effect, however: Are clients better liked by their therapist because they do well in therapy, or does being well liked promote more effort and a greater sense of well-being?61

• A study on inpatient group therapy for the treatment of PTSD in active military personnel demonstrated the significant contribution of group cohesion in effective outcomes. Group cohesion contributed a remarkable 50 percent of the variance to the outcome, and each soldier’s capacity and willingness to work with others in the group was a significant and unique predictor of outcome.62

• Evaluation of outcomes in brief intensive American Group Psychotherapy Association Institute training groups were influenced by higher levels of engagement.63 Positive outcomes may well be mediated by group engagement that fosters more interpersonal communication and self-disclosure.64

• Similar findings were reported in intensive experiential group training for 170 psychiatry residents who ranked group cohesion very highly in promoting openness to self-disclosure and feedback.65

• There is good evidence that individual attachment style also influences the relationship between cohesion and outcome. Individuals with anxious attachment who seek security benefit from group cohesion; but group members with a dismissive and avoidant attachment style may reject the strong pull to join and may need to be supported to work in the group at a pace tailored to them.66

A study of 327 group members treated in intensive inpatient programs that centered on psychodynamic groups meeting twice weekly for twelve weeks showed a significant correlation between group cohesion and outcome but with some variations. Interpersonal style also impacts the cohesion-outcome relationship. Group cohesion was of particular importance for members who had a cold and controlling interpersonal style and were harder to engage than more submissive group members.67

• Fit matters! A large body of research underscores this. The more the individual’s sense of engagement with the group aligns with the engagement level of the group as a whole, the stronger the relationship between engagement and outcome.68 Fit is also influenced by cultural norms. Western attitudes toward authority, emotional expression, self-disclosure, and individualism may contrast with other traditions.69

• Studies also show that group leaders tend to overestimate the degree of cohesion in their groups and their clients’ attraction and connection to their groups. Providing group leaders with ong

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