Yalom Chapter 3 and 11 Corey Chapter 4

Open Versus Closed Groups

In a closed group, no new members are added for the predetermined duration of its life. This practice offers a stability that makes continuity possible and fosters cohesion among group members. If too many members drop out of a closed group, however, the group process is drastically affected. A disadvantage of the open group is that new members may have a difficult time becoming part of the group because they are not aware of what has been discussed before they joined. Another disadvantage is that changing group membership can have adverse effects on the cohesion of the group.

Group Stages

" The boundaries between phases are not clearly demarcated, nor does a group permanently graduate from one phase" (Yalom, 1995). It is common for groups to re-visit earlier stages, yet "from a different perspective and each time in greater depth" (Yalom, 2005).

Turnover

In the normal course of events, a substantial number of members drop out of interactionally based groups in the first twelve meetings Prior individual therapy decreases risk Patients in combined therapy decreases risk

Possible Problems

Members may wait passively for "something to happen." Members may keep to themselves feelings of distrust or fears pertaining to the group and thus entrench their own resistance. Members may keep themselves vague and unknown, making meaningful interaction difficult. Members may adopt a problem-solving and advice-giving stance with other members.

Common issues within the third stage

Morale increases Mutual trust Improved self disclosure Sexual secrets shared Postgroup meetings Concern with intimacy and closeness Intermember support Pride and unity of group

Common issues within the second stage

Struggle for control Hostility towards the therapist Possible feelings of betrayal by the therapist Attacking vs. defending leader Emergence of displaced aggression

Member Functions

Taking active steps to create a trusting climate Learning to express one's feelings and thoughts, especially as they pertain to interactions in the group Being willing to express fears, hopes, concerns, reservations, and expectations concerning the group Being willing to make oneself known to others in the group Being involved in the creation of group norms Establishing personal and specific goals that will govern group participation Learning the basics of group process, especially how to be involved in group interactions

Stage 3: Transition Stage—Dealing With Reluctance

Before a group can begin doing a deeper level of work, it typically goes through a somewhat challenging transition phase. During this stage, members deal with their anxiety, defensiveness, conflict, and ambivalence about participating in the group. If a level of trust has been established during the initial stage, members are usually willing to express certain feelings, thoughts, and reactions that they may not have been willing to verbalize during earlier sessions.

reactance theory

Beutler, Moleiro, and Talebi (2002) view resistance through the lens of reactance theory, which holds that we experience psychological reactance at those times when we believe free behaviors are being threatened with elimination. Reactance theory conceptualizes resistance as a normal process aimed at protecting our sense of personal freedom rather than as a pathological process. Decreasing reluctant behavior in a group is rarely accomplished by labeling participants as "resistant group members." By using more descriptive and nonjudgmental terminology, it is likely that leaders will change their attitude toward members who appear to be "difficult"

homogeneous group

Composed of people who, for example, are similar in ages, such as a group for children, for adolescents, or for older persons. They may also be based on a common interest or problem. The unitary focus in this type of group tends to foster group cohesion, and common problem areas of group members promote sharing experience and learning from one another.

Short-Term Versus Long-Term Groups

The duration varies from group to group, depending on the type of group, the population, and the requirements of the agency. Many community agencies have policies that limit groups to a relatively short duration. For brief group therapy, length of treatment is a defining characteristic. Time-limited groups have a specific focus, and interventions have the aim of being as efficient as possible.

The Division of Responsibility

Both styles of leadership have certain advantages, but they have disadvantages as well. A disadvantage of an active leadership style is that it does not encourage members to assume the responsibility that is rightfully theirs. A disadvantage of a passive leadership style is that it does not foster a collaborative relationship between the leader and the members. Ideally, you will discover a balanced style, accepting a rightful share of the responsibility but not usurping the members' responsibility.

Yalom believes that two common tasks confront a newly formed group:

Determine a method of achieving their primary task Attend to the social relationships in the group

Primary Tasks of the Initial Stage: Inclusion and Identity

Finding an identity in the group and determining the degree to which one will become an active group member are the major tasks of the initial stage. Members often ask themselves these questions at the initial sessions: Will I be accepted or rejected by this group? How much do I want to reveal of myself? How much do I want to risk? Can I trust people in this group? Do I fit and belong in here? Whom am I drawn to, and whom do I feel distant from? Can I be myself and, at the same time, be a part of the group?

Second stage: Conflict, Domination, and Rebellion

Group moves from "in or out" to that of "top or bottom". A control hierarchy, a social pecking order emerges (Yalom, 2005). Members attempt to determine how much power and initiative they want in the group. In this second, "storming" stage, the group shifts from preoccupation with acceptance, approval, commitment to the group, definitions of accepted behavior, and the search for orientation, structure, and meaning, to a preoccupation with dominance, control, and power. The conflict characteristic of this phase is among members or between members and leader. Each member attempts to establish his or her preferred amount of initiative and power. Gradually, a control hierarchy, a social pecking order, emerges. Negative comments and intermember criticism are more frequent; members often appear to feel entitled to a one-way analysis and judgment of others. As in the first stage, advice is given but in the context of a different social code: social conventions are abandoned, and members feel free to make personal criticism about a complainer's behavior or attitudes. Hostility toward the leader has its source in the unrealistic, indeed magical, attributes with which clients secretly imbue the therapist. Their expectations are so limitless that they are bound to be disappointed by any therapist, however competent. Yet another source of resentment toward the leader lies in the gradual recognition by each member that he or she will not become the leader's favorite child. Other members invariably side with the therapist. They must be helped to investigate their need to defend the therapist at all costs, regardless of the issue involved. Occasionally, clients defend you because they have encountered a series of unreliable objects and misperceive you as extraordinarily frail; others need to preserve you because they fantasize an eventual alliance with you against other powerful members of the group. Beware that you do not unknowingly transmit covert signals of personal distress to which the rescuers appropriately respond. Yet another source of group conflict originates in the intrinsic process of change. Rigidly entrenched attitudes and behavioral patterns are challenged by other members, and each individual is faced with the discomfort of letting go of old patterns. A useful paradigm of change in group work consists of the sequence of unfreezing, change, and refreezing. 25 The stage of "unfreezing" naturally entails a degree of challenge and conflict. Individuals adhere to their beliefs about relationships and cling to what is familiar to them. At first many clients lack the ability to examine themselves and to accept feedback. Gradually clients acquire the capacity to participate, feel emotion, and then reflect on that experience.

Announcing a Group and Recruiting Members

It is imperative that you say enough to give prospective members a clear idea about the group's rationale and goals. When recruiting potential members for a group, I am in favor of making direct contact with the population that is most likely to benefit from the group. You could also distribute a brief application form to anyone who wanted to find out more about the group.

Group Size

The desirable size for a group depends on factors such as the age of the clients, the type of group, the experience of the group counselors, and the type of problems explored. Another element to be taken into consideration is whether the group has one leader or more. For ongoing groups with adults, about eight members with one leader seems to be a good size. Groups with children may be as small as three or four.

Stage 2: Initial Stage—Orientation and Exploration

The initial stage of a group is a time of orientation and exploration: determining the structure of the group, getting acquainted, and exploring the members' expectations. During this phase, members learn how the group functions, define their own goals, clarify their expectations, and look for their place in the group. At the initial sessions members tend to keep a "public image"; that is, they present the dimensions of themselves they consider socially acceptable. This phase is generally characterized by a certain degree of anxiety and insecurity about the structure of the group. Members are tentative because they are discovering and testing limits and are wondering whether they will be accepted. Typically, members bring to the group certain expectations, concerns, and anxieties, and it is vital that they be allowed to express them openly. At this time the leader needs to clear up any misconceptions and, if necessary, demystify groups.

The Departing Member: Therapeutic Considerations.

When a client is asked to leave or chooses to leave a group, the therapist must endeavor to make the experience as constructive as possible. Such clients ordinarily are considerably demoralized and tend to view the group experience as one more failure. Even if the client denies this feeling, the therapist should still assume that it is present and, in a private discussion, provide alternative methods of viewing the experience.

Summary of the Transition Stage Stage Characteristics

Wonder what they will think of themselves if they increase their self-awareness, and wonder about others' acceptance or rejection of them Test the leader and other members to determine how safe the environment is Experience some struggle for control and power and some conflict with other members or the leader Learn how to work through conflict and confrontation Feel reluctant to get fully involved in working on their personal concerns because they are not sure others in the group will care about them Observe the leader to determine if he or she is trustworthy and learn from this person how to resolve conflict Learn how to express themselves so that others will listen to them

Group Cohesiveness and Other Therapy-Relevant Variables

1. Try harder to influence other group members 2. Be more open to influence by the other members 3. Be more willing to listen to others109 and more accepting of others 4. Experience greater security and relief from tension in the group 5. Participate more readily in meetings 6. Self-disclose more 7. Protect the group norms and exert more pressure on individuals deviating from the norms 8. Be less susceptible to disruption as a group when a member terminates membership 9. Experience greater ownership of the group therapy enterprise

Voluntary Versus Involuntary Membership

Attending a group because one has been "sent" there by someone often minimizes the chance of success. However, many of the negative attitudes that involuntary candidates have about groups can be changed by adequately preparing members for a group. I have found that many involuntary members learn that a group counseling experience can help them make some of the changes they want. By presenting the group experience in a favorable light, the leader can help involuntary members see the potential benefits of the experience and the chance of productive work taking place will be increased. However, it probably will take more time and work to achieve a level of trust in an involuntary group. The key to successful participation lies in thorough member orientation and preparation and in the leader's belief that the group process has something to offer to these prospective members.

Member Functions and Possible Problems

Before joining a group, individuals need to have the knowledge necessary for making an informed decision concerning their participation. Potential members should be active participants in deciding whether a group is right for them. Here are some issues that pertain to the role of members at this stage: Members should have adequate knowledge about the nature of the group and understand the impact the group may have on them. Members need to determine whether a particular group is appropriate for them at this time. Members can profit by preparing themselves for the upcoming group by thinking about what they want from the experience and identifying personal themes that will guide their work in a group. Problems can arise if members are coerced into a group, do not have adequate information about the nature of the group, or are passive and give no thought to what they want or expect from the group.

The Foundation of the Group: Trust

Establishing trust is vital to the continued development of the group. Without trust, group interaction will be superficial, little self-exploration will take place, constructive challenging of one another will not occur, and the group will operate under the handicap of hidden feelings.

FORMATIVE STAGES OF THE GROUP

In general, groups are first preoccupied with the tasks of initial member engagement and affiliation. This phase is followed by one with a focus on control, power, status, competition, and individual differentiation. Next comes a long, productive working phase marked by intimacy, engagement, and genuine cohesion. The final stage is termination of the group experience. As group development unfolds, we see shifts in group member behavior and communication. As the group matures, increased empathic, positive communication will be evident. Members describe their experience in more personal, affective and less intellectual ways. Group members focus more on the here-and-now, are less avoidant of productive conflict, offer constructive feedback, are more disclosing, and are more collaborative. Advice is replaced with exploration, and the group is more interactional, self-directed and less leader centered.3 This developmental shift to more meaningful work has also been demonstrated repeatedly in reliable studies of task and work groups and correlates significantly with enhanced productivity and achievement.

The First Meeting

The first group therapy session is invariably a success. Clients (as well as neophyte therapists) generally anticipate it with such dread that they are always relieved by the actual event. Any actions therapists take to reduce clients' anxiety and unease are generally useful. It is often helpful to call members a few days before the first meeting to reestablish contact and remind them of the group's beginning. Some therapists begin the meeting with a brief introductory statement about the purpose and method of the group (especially if they have not thoroughly prepared the clients beforehand); others may simply mention one or two basic ground rules—for example, honesty and confidentiality.

Group Cohesiveness and Group Attendance

The relationship between cohesiveness and maintenance of membership has implications for the total group as well. Not only do the least cohesive members terminate membership and fail to benefit from therapy, but noncohesive groups with high member turnover prove to be less therapeutic for the remaining members as well. Clients who drop out challenge the group's sense of worth and effectiveness.

Characteristics of the Transition Stage

The transition stage is generally characterized by increased anxiety and defensiveness. These feelings normally give way to genuine openness and trust in the stages that follow. Anxiety grows out of the fear of letting others see beyond the level of a person's public image. Anxiety also results from the fear of being judged and misunderstood, from the need for more structure, and from a lack of clarity about goals, norms, and expected behavior in the group situation. As the participants come to trust more fully the other members and the leader, they become increasingly able to share of themselves, and this openness lessens their anxiety about letting others see them as they are.

THE IMPORTANCE OF GROUP COHESIVENESS

Although I have discussed 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 that is important; it is not only 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 seem 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 us all. Both affiliation within the group and attachment in the individual setting address this need.22 Therapy groups generate a positive, self-reinforcing loop: trust-self-disclosure-empathy-acceptance-trust. Most of our clients, however, have an impoverished group history; they have never been valuable and integral to a group. For these individuals, the sheer successful negotiation of a group experience may in itself be curative. Belonging in the group raises self-esteem and meets members' dependency needs but in ways that also foster responsibility and autonomy, as each member contributes to the group's welfare and internalizes the atmosphere of a cohesive group.

Ways of Maintaining Trust

Another characteristic of this initial phase is the tendency for some participants to jump in and try to give helpful advice as problems are brought up. It is the leader's task to make sure that these "problem-solving interventions" do not become a pattern; they may cause enough irritation in other members to precipitate a confrontation with those who are quick to offer remedies for everyone's troubles. The group's atmosphere of trust is also affected by the negative feelings members often experience at the initial stage toward certain other members or toward the leader and over the fact that the group is not proceeding the way they would like to see it proceed. This is an important turning point in a group, and trust can be lost or enhanced depending on the manner in which conflict is dealt with. If conflict is brought out into the open and negative feelings are listened to nondefensively, there is a good chance that the situation producing these feelings can be changed. As members reveal more of themselves, the group becomes cohesive; in turn, this emerging cohesion strengthens the trust that exists in the group and creates the right atmosphere for members to try new ways of being in the group.

Screening and Selecting Group Members

As you screen and select group members, ask yourself these two questions: "How can I decide who is most likely to benefit from this group?" "Who is likely to be disturbed by group participation or be a negative influence for the other members?" If you have an open group, you would want to ask this question as well: "How might this potential member fit with members already in the group?" If screening is not possible, the initial group meeting can be structured as an information and orientation session. Once potential members have been recruited, the leader must determine who (if anyone) should be excluded. Careful screening will lessen the psychological risks of inappropriate participation in a group. During the screening session, the leader can spend some time exploring with potential members any fears or concerns they have about participating in a group. The leader can help members make an assessment of their readiness for a group and discuss the potential life changes that might come about. Members can benefit from knowing that there is a price for remaining the same as well as for making substantive changes. Screening should be a two-way process, and potential members should have an opportunity at the private screening interview to ask questions to determine whether the group and the leader are right for them. Group leaders should encourage prospective members to be involved in the decision concerning the appropriateness of their participation in the group. It is sometimes difficult to determine which candidates will benefit from a group. According to Burlingame, Fuhriman, and Johnson (2002), people who should probably be excluded from a group include those who are actively psychotic or organically impaired, those severely limited in interpersonal skills and impervious to feedback, and those who are unable or unwilling to abide by a contract. Others who should generally be excluded from most groups are people who are in a state of extreme crisis, who are suicidal, who have sociopathic personalities, who are highly suspicious, or who are lacking in ego strength and are prone to fragmented and bizarre behavior. n terms of criteria for inclusion, Yalom contends that the client's level of motivation to work is the most important variable. From his perspective, groups are useful for people who have interpersonal problems such as loneliness, an inability to make or maintain intimate contacts, feelings of being unlovable, fears of being assertive, and dependency. Individuals who lack meaning in life, who suffer from diffuse anxiety, who are searching for an identity, who fear success, and who are compulsive workers might also profit from a group experience.

Helping Identify Goals

At this stage you do it mostly by helping members identify, clarify, and develop meaningful goals. There are general group goals, which vary depending on the purpose of the group, and there are group process goals, which apply to most groups. In addition to establishing these group process goals, members may need help in establishing their own personal goals. It is important for you to help members see the relationship between group process goals and their individual goals so that they can invest in both. Typically, people in the early stages of a group have vague ideas about what they want. These unclear expectations need to be translated into specific, concrete goals with regard to the desired changes and to the efforts the person is willing to make to bring about changes. It is clear that cultural factors need to be considered in helping members identify their personal goals.

Recognizing and Dealing With Conflict

Before conflict can be dealt with and constructively worked through, it must be recognized. Too often both the members and the leader want to bypass conflict out of the mistaken assumption that it is something to be feared and avoided at all costs. When conflict is recognized and dealt with in such a way that those who are involved can retain integrity, the foundations of trust between the parties are established. Recognizing that conflict is often inevitable and that it can strengthen trust is likely to reduce the probability that members and the leader will try to dodge the conflicts that are a natural part of a group's development. As a group evolves, members continue to discover whether the group is a safe place to disagree, to have and express the full range of feelings, and to experience interpersonal conflict. They are testing the degree to which they can be accepted when they are not living up to social expectations. The way conflict is recognized, accepted, and worked with has critical effects on the progress of the group. If it is poorly handled, the group will probably not reach a productive stage of development. Intermember conflict is often the result of transference. Members may have intense reactions to one another; by exploring these reactions to specific individuals in a group, members can discover some important connections to the ways in which they transfer feelings from significant people in their lives to others.

SUMMARY

By definition, cohesiveness refers to the attraction that members have for their group and for the other members. It is experienced at interpersonal, intrapersonal, and intragroup levels. The members of a cohesive group are accepting of one another, supportive, and inclined to form meaningful relationships in the group. Cohesiveness is a significant factor in successful group therapy outcome. In conditions of acceptance and understanding, members will be more inclined to express and explore themselves, to become aware of and integrate hitherto unacceptable aspects of self, and to relate more deeply to others. Self-esteem is greatly influenced by the client's role in a cohesive group. The social behavior required for members to be esteemed by the group is socially adaptive to the individual out of the group. In addition, highly cohesive groups are more stable groups, with better attendance and less turnover. Evidence was presented to indicate that this stability is vital to successful therapy: early termination precludes benefit for the involved client and impedes the progress of the rest of the group as well. Cohesiveness favors self-disclosure, risk taking, and the constructive expression of conflict in the group—phenomenon that facilitate successful therapy.

Evidence

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. Members' self-perceived personality change correlated significantly with both their feelings of involvement in the group and their assessment of total group cohesiveness. therapy. Positive outcome in therapy significantly correlated with only two predictor variables: group cohesiveness36 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 the twelfth weeks had a better therapy outcome at the fiftieth week. 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.

Challenging the Group Leader

Conflicts also often involve the group leader. You may be challenged on professional as well as personal grounds. You may be criticized for being "too standoffish" and not revealing enough of yourself, or members may take issue with you for being "one of the group" and revealing too much of your private life. It is helpful to distinguish between a challenge and an attack. An attack can take the form of "dumping" or "hit-and-run" behavior. Members who attack group leaders with "This is how you are" statements don't give leaders much chance to respond. The leader has already been judged, categorized, and dismissed. Confronting the leader is often a participant's first significant step toward self-direction. Most members experience the struggle of dependence versus independence. If members are to become free of their dependency on the leader that is characteristic of the initial group stage, the leader must deal directly with these revealing challenges to his or her authority. The way in which you accept and deal with challenges to you personally and to your leadership style greatly determines your effectiveness in leading the group into more advanced levels of development. If you can learn to appreciate the opportunities that challenges from group members offer, you have a better chance of dealing with these interactions directly, nondefensively, and honestly.

Dropouts

Dropouts: It is a significant problem, and may be reduced by: Proper selection of participants Pre-therapy preparation Consider dropping patients that are not working or benefitting from the group 8). It is often productive to think about the dropout phenomenon from the perspective of the interaction of three factors: the client, the group, and the therapist.61 In general, client contributions stem from problems caused by deviancy, conflicts in intimacy and disclosure, the role of the early provocateur, external stress, complications of concurrent individual and group therapy, inability to share the leader, and fear of emotional contagion. Underlying all these reasons is the potential stress early in the group. Individuals who have maladaptive interpersonal patterns are exposed to unaccustomed demands for candor and intimacy; they are often confused about procedure; they suspect that the group activities bear little relevance to their problem; and, finally, they feel too little support in the early meetings to sustain their hope. Group factors include the consequences of subgrouping, poor compositional match of clients, scapegoating, member-member impasses, or unresolved conflict. The therapists also play a role: they may select members too hurriedly, they may not prepare members adequately, they may not attend to building group cohesion, or they may be influenced by unresolved countertransference reactions. Generally, the therapist is well advised to see a potential dropout for a short series of individual interviews to discuss the sources of group stress. Occasionally an accurate, penetrating interpretation will keep a client in therapy. In general the therapist can decrease premature termination by attending assiduously to early phase problems.

Impact of Patients on Group development

Heavily influenced by the composition of group members Need to understand role of "early provocateurs", that typically activate the group and possibly drop out prematurely. Other individuals who may alter typical group developmental trends include those with monopolistic proclivities, exhibitionism, promiscuous self-disclosure, or an unbridled inclination to exert control. Not infrequently, such individuals receive covert encouragement from the therapist and other group members. Therapists value these clients because they provide a focus of irritation in the group, stimulate the expression of affect, and enhance the interest and excitement of a meeting. The other members often initially welcome the opportunity to hide behind the protagonist as they themselves hesitantly examine the terrain. In a study of the dropouts of nine therapy groups, I found that in five of them, a client with a characteristic pattern of behavior fled the therapy group within the first dozen meetings.45 These clients ("early provocateurs") differed from one another dynamically but assumed a similar role in the group Therapists must recognize this phenomenon early in the group and, through clarification and interpretation of their role, help prevent these individuals from committing social suicide. Perhaps even more important, therapists must recognize and discontinue their own covert encouragement of the early provocateur's behavior. It is useful for therapists to take note of their reactions to the absence of the various members of the group. If some members are never absent, you may fantasize their absences and your reaction to it. Consider what thoughts, feelings, fantasies and actions these individuals generate in you, and what they do to generate that impact. In summary, there are some advantages to group therapists' possessing some broad schema of a group developmental sequence: It enables them to maintain objectivity and to chart the voyage of a group despite considerable yawing, and to recognize if a group never progresses past a certain stage or omits some. At times, therapists may demand something for which the group is not yet ready: mutual caring and concern develop late in the group; in the beginning, caring may be more pro forma as members view one another as interlopers or rivals for the healing touch of the therapist. The therapist who is aware of normative group development is able to remain more finely tuned to the group. But there is a downside to the clinical application of group developmental ideas. The inexperienced therapist may take them too seriously and use them as a template for clinical practice. I have seen beginning therapists exert energy on forcing a group, in procrustean fashion, to progress in lockstep through set phases.

Guidelines for Orientation and Preparation of Members

I begin my preparation program at the time of screening each potential member, and I devote most of the first group meeting (what I call the pregroup meeting) to orientation about group process. During the pregroup meeting and continuing into the initial group sessions, I view my role as helping members examine and decide on their level of commitment. We focus on what they want to get from participating in a group, and I assist them in defining clear, specific, and meaningful personal goals. After they have decided on some personal goals that will guide their work in the group, they are asked to refine these goals by developing a contract. At the pregroup meeting I ask members to raise any questions they have about the group and encourage members to talk about their expectations, their reasons for being in the group, their fears or concerns about participating, and their hopes. I also provide some guidelines on what members can do to maximize the benefit of the group in enabling them to make the changes they desire in their lives. Especially important is a discussion regarding the rationale for appropriate self-disclosure. Members are told that it is their decision to select the personal themes they want to explore in the group. They also hear that it is critical that they be willing to share persistent reactions they are having to here-and-now group interactions. My purpose is to teach them that the group will function only if they are willing to express what they are thinking and feeling about being in the group. Members are asked to give some thought before they come to each session about personal issues they are willing to bring up for exploration. Although they may have a specific agenda when they come to a group meeting, I encourage them to remain flexible by being willing to work on other concerns that may emerge spontaneously as others are interacting in the group. Group members are typically asked to keep a journal and to spontaneously write about the range of reactions they have while they are in the group as well as reactions to what they experience between the sessions.

Summary

I have cited evidence that group members value deeply the acceptance and support they receive from their therapy group. Self-perceived therapy outcome is positively correlated with attraction to the group. Highly cohesive groups have a better overall outcome than groups with low esprit de corps. Both emotional connectedness and the experience of group effectiveness contribute to group cohesiveness. Individuals with positive outcomes have had more mutually satisfying relationships with other members. Highly cohesive groups have greater levels of self-disclosure. For some clients and some groups (especially highly structured groups) the relationship with the leader may be the essential factor. A strong therapeutic relationship may not guarantee a positive outcome, but a poor therapeutic relationship will certainly not result in an effective treatment. The presence of cohesion early in each session as well as in the early sessions of the group correlates with positive outcomes. It is critical that groups become cohesive and that leaders be alert to each member's personal experience of the group and address problems with cohesion quickly. Positive client outcome is also correlated with group popularity, a variable closely related to group support and acceptance. Although therapeutic change is multidimensional, these findings taken together strongly support the contention that group cohesiveness is an important determinant of positive therapeutic outcome.

Stage 1: Pregroup Issues—Formation of the Group

Ideally, planning begins with drafting a written proposal containing the basic purposes of the group, the population to be served, a clear rationale for the group—namely, the need for and justification of that particular group—ways to announce the group and recruit members, the screening and selection process for members, the size and duration of the group, the frequency and time of meetings, the group structure and format, the methods of preparing members, whether the group will be open or closed, whether membership will be voluntary or involuntary, and the follow-up and evaluation procedures.

Leader Functions

Identify the general goals and specific purposes of the group. Develop a clearly written proposal for the formation of a group. Conduct pregroup interviews for screening and orientation purposes. Make decisions concerning the selection of members. Prepare psychologically for leadership tasks and meet with a coleader (if appropriate). Arrange for a preliminary group session to get acquainted, present ground rules, and prepare members for a successful group experience. Make provisions for informed consent and explore with participants the potential risks and benefits involved in a group experience.

The Initial Stage: Orientation, Hesitant Participation, Search for Meaning, Dependency

Initial stage of group is characterized by " a search for structure and goals"(Yalom, 2005). Introductions, ground rules and issues of confidentiality are usually common items of discussion. Several simultaneous concerns are present in the initial meetings. Members, especially if not well prepared by the therapist, search for the rationale of therapy; they may be confused about the relevance of the group's activities to their personal goals in therapy. They search for viable roles for themselves and wonder whether they will be liked and respected or ignored and rejected. Although clients ostensibly come to a therapy group for treatment, social forces impel them to invest most of their energy in a search for approval, acceptance, respect, or domination. If the early group is puzzled, testing, and hesitant, then it is also dependent. Overtly and covertly, members look to the leader for structure and answers as well as for approval and acceptance. The existence of initial dependency thus stems from many sources: the therapeutic setting, the therapist's behavior, a morbid dependency state on the part of the client and, as I discussed in chapter 7, the many irrational sources of the members' powerful feelings toward the therapist. The content and communicational style of the initial phase tends to be relatively stereotyped and restricted, resembling the interaction occurring at a cocktail party or similar transient social encounters. In the beginning, therapy groups often spend time on symptom description, previous therapy experience, medications, and the like. The members often search for similarities. Giving and seeking advice is another characteristic of the early group: clients seek advice for problems with spouses, children, employers, and so on, and the group attempts to provide some practical solution. In the beginning the group needs direction and structure. A silent leader will amplify anxiety and foster regression.† This phenomenon occurs even in groups of psychologically sophisticated members.

Group Cohesiveness and the Expression of Hostility

It would be a mistake to equate cohesiveness with comfort. Although cohesive groups may show greater acceptance, intimacy, and understanding, there is evidence that they also permit greater development and expression of hostility and conflict. Cohesive groups have norms (that is, unwritten rules of behavior accepted by group members) that encourage open expression of disagreement or conflict alongside support. Conflict may also enhance self-disclosure, as each opponent tends to reveal more and more to clarify his or her position. As members are able to go beyond the mere statement of position, as they begin to understand the other's experiential world, past and present, and view the other's position from their own frame of reference, they may begin to understand that the other's point of view may be as appropriate for that person as their own is for themselves. One cautionary note about cohesion: misguided ideas about cohesion may interfere with the group task.102 Janis coined the term "groupthink" to describe the phenomenon of "deterioration of mental efficiency, reality testing, and moral judgment that results from group pressure."103 Group pressure to conform and maintain consensus may create a groupthink environment. This is not an alliance-based cohesion that facilitates the growth of the group members; on the contrary, it is a misalliance based on naive or regressive assumptions about belonging. Critical and analytic thought by the group members needs to be endorsed and encouraged by the group leader as an essential group norm.

Ways of Establishing Trust

Leaders who show that they are interested in the welfare of individual members and of the group as a whole engender trust. Talking about matters such as the rights of participants, the necessity of confidentiality, the diversity that exists within the group, and the need for respecting others demonstrates that the leader has a serious attitude toward the group and values the rights of the individual. Participants will trust the group more if they are encouraged to expose their fears, because talking about them is likely to reveal that others share their fears. Silences and awkwardness are characteristically part of the beginning session. The more unstructured the group, the greater the anxiety and ambiguity about how one is to behave in a group. The members are floundering somewhat as they seek to discover how to participate. More often than not, in these initial sessions, the issues raised tend to be safe ones, and there is some talking about other people and there-and-then material.

Summary of the Transition Stage Possible Problems

Members can be categorized as a "problem type," or they can limit themselves with a self-imposed label. Members may refuse to express persistent negative reactions, thus contributing to the climate of distrust. If confrontations are poorly handled, members may retreat into defensive postures and issues will remain hidden. Members may identify a scapegoat and project their own feelings onto that person. Members may collude by forming subgroups and cliques, expressing negative reactions outside of the group but remaining silent in the group.

Difficult Group Member, or Difficult Group Leader?

Members exhibit problematic or defensive behaviors at times because of problematic behaviors on the part of group leaders. Even in effective groups, certain members may manifest problematic behaviors that are a source of difficulty to themselves, other members, and the leader. Learning how to deal therapeutically with resistance and the many forms it takes is a central challenge for group leaders. The best way to deal therapeutically with difficult member behaviors is to simply describe what we are observing and let members know how we are affected by what we see and hear. This approach is an invitation for members to determine whether what they are doing is working for them. Here are some guidelines for effectively dealing with members who sometimes can be challenging: Express annoyance with a member without denigrating the character of the person. Avoid responding to a sarcastic remark with sarcasm. Educate the member about how the group works to demystify the process. Encourage a member to explore his or her fears or any form of resistance rather than ignore them. Avoid labeling and judging any member and instead describe the behavior of the member. State observations and hunches in a tentative way rather than being dogmatic. Demonstrate sensitivity to a member's culture and avoid stereotyping the individual. Let members who are difficult for you know how they are affecting you in a nonblaming way. Avoid using the role and power of the leader to intimidate members. Monitor your own countertransference reactions. Challenge members in a caring and respectful way to do things that may be painful and difficult. Avoid retreating when conflict arises. Provide a balance between support and challenge. Refrain from taking member reactions in an overly personal way. Facilitate a more focused exploration of a problem rather than give simple solutions. Meet the member's needs, not your own. Invite group members to state how they are personally affected by problematic behaviors of other members, but block judgments, evaluations, and criticisms. When working with a group member who exhibits difficult behaviors, put these behavioral patterns into the context of the meaning and purpose of this behavior for the individual. People in a group are likely doing the best they know how, even if they become aware that what they are doing is not working well for them. It is always useful to remind ourselves that the very reason people seek a group is to assist them in finding more effective ways of expressing themselves and dealing with others.

Frequency and Length of Meetings

Once a week is a typical format for most counseling groups. With children and adolescents, it is usually better to meet more frequently for shorter sessions. For adults who are functioning relatively well, a 2-hour group each week is long enough to allow for some intensive work. Outpatient groups often meet for a 90-minute session, whereas inpatient groups may have shorter sessions.

Stage Characteristics

Participants test the atmosphere and get acquainted. Members learn what is expected, how the group functions, and how to participate in a group. Members display socially acceptable behavior; risk-taking is relatively low and exploration is tentative. Group cohesion and trust are gradually established if members are willing to express what they are thinking and feeling. Members are concerned with whether they are included or excluded, and they are beginning to define their place in the group. A central issue is trust versus mistrust. There are periods of silence and awkwardness; members may look for direction and wonder what the group is about. Members are deciding whom they can trust, how much they will disclose, how safe the group is, and how much to get involved. Members are learning the basic attitudes of respect, empathy, acceptance, caring, and responding—all attitudes that facilitate trust building.

Summary of the Transition Stage Leader Functions

Perhaps the central challenge that leaders face during the transition phase is the need to intervene in the group in a sensitive manner and at the right time. The basic task is to provide both the encouragement and the challenge necessary for the members to face and resolve the conflicts that exist within the group and their own defenses against anxiety. Teach group members the importance of recognizing and expressing their anxieties, reluctances, and here-and-now reactions to what is happening in the sessions. Help participants recognize the ways in which they react defensively and create a climate in which they can deal with their resistances openly. Teach the members the value of recognizing and dealing openly with conflicts that occur in the group. Point out behavior that is a manifestation of the struggle for control, and teach members how to accept their share of responsibility for the direction of the group. Assist group members in dealing with any matters that will influence their ability to become both independent and interdependent. Encourage members to keep in mind what they want from the group and to ask for it. Provide a model for the members by dealing directly and honestly with any challenges to you as a person or as a professional. Continue to monitor your own reactions to members who display problematic behavior. Explore your potential countertransference through supervision or personal therapy. During the transition stage, active intervention and structuring are important because generally the participants have not yet learned to work effectively on their own. If a conflict arises, for example, some members may attempt to move on to more pleasant topics or in some other way ignore the conflict. Group leaders need to teach members constructive ways to deal with conflict and the value of expressing their feelings, thoughts, and reactions to such conflicts.

The Uses of a Pregroup Meeting or the Initial Session

Preparation may consist of exploring with members some of the following: their expectations, fears, goals, and misconceptions; the basics of group process; the psychological risks associated with group membership and ways of minimizing them; the values and limitations of groups; guidelines for getting the most from the group experience; and the necessity of confidentiality. Because I prefer to have people decide early if they are ready for a group and willing to become active members, I encourage participants to consider the first session as an opportunity to help them make such a decision. Structuring the group, including the specification of norms and procedures, should be accomplished early in the group's history. Although structuring begins at the private intake session, it will be necessary to continue this process the first time the group actually meets. In fact, structuring is an ongoing process that is a vital part of the early phases of your group. Some group members expect a low degree of structure, and others prefer a group that is highly structured with clearly defined tasks.

Meeting Place

Privacy, a certain degree of attractiveness, and a place that allows for face-to-face interaction are crucial. A poor setting can set a negative tone that will adversely affect the cohesion of the group, so every effort should be made to secure a meeting place that will facilitate in-depth work.

Structuring

Providing therapeutic structuring is particularly important during the initial stage when members are typically confused about what behavior is expected in the group and are therefore anxious. Structure can be either useful or inhibiting in a group's development. Too little structure results in members' becoming unduly anxious, which inhibits their spontaneity. Too much structuring and direction can foster dependent attitudes and behavior. The leader must carefully monitor and assess this therapeutic structure throughout the life of a group rather than waiting to evaluate it during the final stage. Structuring that offers a coherent framework for understanding the experiences of individuals and the group process will be of the most value Leader direction during the early phases of a group tends to foster cohesion and the willingness of members to take risks by making themselves known to others and by giving others feedback. Group cohesion is a key element for a productive group experience. Once cohesion is established, therapeutic interventions that involve risk-taking on the part of members can be introduced, and these exercises often result in catharsis and insights Another leader task during the early stage of a group involves being aware of the nature of members' concerns about self-disclosure. Leaders can intervene by helping members identify and process their concerns early in the life of a group. There is research indicating that early structure provided by the leader tends to increase the frequency of therapeutically meaningful self-disclosure, feedback, and confrontation.

Summary of the Transition Stage Member Functions

Recognizing and expressing the range of feelings and thoughts Respecting their own struggles yet continuing to explore them in group Moving from dependence to independence Taking increased responsibility for what they are doing in the group Learning how to confront others in a constructive manner Being willing to face and deal with reactions toward what is occurring in the group Being willing to work through conflicts rather than avoiding them

Reluctance and Guardedness

Reluctant members may exhibit defensive behaviors, and unless these behaviors are recognized and explored, defensiveness can seriously interfere with the group process. Participants need to become aware of the defenses that may prevent them from getting involved in the group and of the effects of these defenses on the other members. An effective way of dealing with defensive behavior is to treat it as an inevitable aspect of the group process; that is, the leader acknowledges that being guarded is a member's natural response to getting personally involved in a risk-taking experience. An open atmosphere that encourages people to acknowledge and work through whatever hesitations and anxieties they may be experiencing is essential. In other words, group members may be unwilling to share their feelings because they do not trust the group leader or because the group is simply not a safe place in which to open up. Leaders must look honestly at the sources of defensive behavior, keeping in mind that not all ambivalence stems from the members' lack of willingness to face unconscious and threatening sides of themselves. Such clients are not helped to participate more actively by leaders or other members who demonstrate little understanding or appreciation for the underlying cultural values of these clients. For example, silence in a group cannot always be interpreted as a refusal to participate. In some cultures, silence is a customary sign of respect for others; talking too much or interrupting others is considered impolite. Quiet clients may think that being silent is better than talking frequently or verbalizing without careful thought.

Multicultural Considerations in Preparing Members for a Group Experience

Screening, selecting, and orienting members to group procedures are especially critical in working with individuals from diverse cultural groups. Many group members hold values and expectations that make it difficult for them to participate fully in a group experience. In some cultures, individuals are not encouraged to express their feelings openly, to talk about their personal problems with people whom they do not know well, or to tell others what they think about them. he goals, structure, and techniques used in a group should be modified to make the group work culturally appropriate. Group workers need to be aware that reluctance or hesitation to participate fully in a group may be more the result of cultural background than of an uncooperative attitude. Many group members, regardless of their cultural background, may hesitate to reveal personal matters for fear of being judged and of being rejected. In a group situation, members are generally expected to abide by the norms of openness, honesty, and directness, and they are expected to make themselves emotionally vulnerable. Depending on one's cultural background, some group norms may be very demanding and may go against the grain of a member's personal and cultural value system.

Common issues within the first stage:

Search for group rationale Sizing each other up Search for acceptance, approval, attention, respect or domination Search for similarities Advice seeking and advice giving

Homogeneous Versus Heterogeneous Groups

Short-term groups are usually characterized by homogeneous membership. The unitary focus in a homogeneous group tends to foster group cohesion, and common problem areas of group members promote sharing experiences and learning from one another. Although homogeneous membership can be more appropriate for certain target populations with definite needs or with short-term groups, heterogeneous membership has some definite advantages for many personal growth groups, whether short or long term. A heterogeneous group represents a microcosm of the social structure that exists in the everyday world and offers participants the opportunity to experiment with new behaviors, develop social skills, and get feedback from many diverse sources.

Removing a Client from a Group.

Taking a client out of a therapy group is an act of tremendous significance for both that individual and the group. Hence it must be approached thoughtfully. Once a therapist determines that a client is not working effectively, the next step is to identify and remove all possible obstacles to the client's productive engagement in the group. If the therapist has done everything possible yet is still unable to alter the situation, there is every reason to expect one of the following outcomes: (1) the client will ultimately drop out of the group without benefit (or without further benefit); (2) the client may be harmed by further group participation (because of negative interaction or the adverse consequences of the deviant role—see chapter 8); or (3) the client will substantially obstruct the group work for the remaining group members. Whenever you remove a client from the group, you should expect a powerful reaction from the rest of the group. The ejection of a group member stirs up deep levels of anxiety associated with rejection or abandonment by the primal group.

Attendance and punctuality

Tardiness and irregular attendance may signify resistance It is destructive and contagious to the group Inconsistent attendance demands eventual intervention Tardiness and irregular attendance usually signify resistance to therapy and should be regarded as they are in individual therapy. During pretherapy interviews, many therapists stress the importance of regular attendance. Clients who appear likely to have scheduling or transportation problems are best referred for individual therapy, as are those who must be out of town once a month or who, a few weeks after the group begins, plan an extended out-of-town vacation. Charging full fees for missed sessions is standard practice. It is critical that the therapist be utterly convinced of the importance of the therapy group and of regular attendance. The therapist who acts on this conviction will transmit it to the group members. Like any event in the group, absenteeism or tardiness is a form of behavior that reflects an individual's characteristic patterns of relating to others. Be sure to examine the personal meaning of the client's action. Clients who have been absent or are late often enter the meeting with some defensive guilt or shame and are not in an optimal state of receptiveness for observations about their behavior. The therapist does well to attend first to group maintenance and norm-setting tasks and then, later, when the timing seems right and defensiveness diminished, attempt to help the individual explore the meaning of his or her behavior. The timing of feedback is particularly important for members who have greater psychological vulnerability and less mature relationships.

Leader Functions in Initial Stage

Teaching participants some general guidelines and ways to participate actively that will increase their chances of having a productive group Developing ground rules and setting norms Teaching the basics of group process Assisting members in expressing their fears and expectations and working toward the development of trust Modeling the facilitative dimensions of therapeutic behavior Being open with members and being psychologically present for them Clarifying the division of responsibility Helping members establish concrete personal goals Dealing openly with members' concerns and questions Providing a degree of structuring that will neither increase member dependence nor promote excessive floundering Assisting members to share what they are thinking and feeling about what is occurring within the here-and-now group context Teaching members basic interpersonal skills such as active listening and responding Assessing the needs of the group and facilitating in such a way that these needs are met

Third stage: Group Cohesiveness

The group gradually develops into a cohesive unit, free of the conflict and counterdependency associated with the first two stages (Yalom, 2005). In this phase the interpersonal world of the group is one of balance, resonance, safety, increased morale, trust, and self-disclosure.33 Some members reveal the real reason they have come for treatment: sexual secrets and long-buried transgressions are shared. Postgroup coffee meetings may be arranged. Attendance improves, and clients evince considerable concern about missing members. The chief concern of the group is with intimacy and closeness. If we characterize clients' concerns in the first phase as "in or out" and the second as "top or bottom," then we can think of the third phase as "near or far." The members' primary anxieties have to do with not being liked, not being close enough to others, or being too close to others.34 Although there may be greater freedom of self-disclosure in this phase, there may also be communicational restrictions of another sort: often the group suppresses all expression of negative affect in the service of cohesion. Compared with the previous stage of group conflict, all is sweetness and light, and the group basks in the glow of its newly discovered unity. Thus one may think of the stage of growing cohesiveness as consisting of two phases: an early stage of great mutual support (group against external world) and a more advanced stage of group work or true teamwork in which tension emerges not out of the struggle for dominance but out of each member's struggle with his or her own resistances.

Addition of new members

Typically needed when group is 5 or fewer members Hostility is common towards new member Fears include new member will slow group down, become a rival, or threat to group hierarchy. Avoidance of possible re-exposure The success of introducing new members depends in part on proper timing: there are favorable and unfavorable times to add members. Generally, a group that is in crisis, is actively engaged in an internecine struggle, or has suddenly entered into a new phase of development does not favor the addition of new members; it will often reject the newcomers or else evade confrontation with the pressing group issue and instead redirect its energy toward them. There are several reasons for a group's ambivalent response to new members. Some members who highly prize the solidarity and cohesiveness of the group may be threatened by any proposed change to the status quo. Will the new members undermine the group? Powerful sibling rivalry issues may be evoked at the entrance of a new drain on the group's supplies: members may envision newcomers as potential rivals for the therapist's and the group's attention and perceive their own fantasized role as favored child to be in jeopardy.68 Still other members, particularly those conflicted in the area of control and dominance, may regard the new member as a threat to their position in the hierarchy of power. A common concern of a group is that, even though new members are needed, they will nonetheless slow the group down. The group fears that familiar material will have to be repeated for the newcomers and that the group must recycle and relive the tedious stages of gradual social introduction and ritualistic etiquette. I tell clients that they can expect feelings of exclusion and bewilderment on entering an unusual culture, and I reassure them that they will be allowed to enter and participate at their own rate. New clients entering established groups may be daunted by the sophistication, openness, interpersonal facility, and daring of more experienced members; they may also be frightened or fear contagion, since they are immediately confronted with members revealing more of their pathology than is revealed in the first meetings of a new group. These contingencies should be discussed with the client. It is generally helpful to describe to the incoming participant the major events of the past few meetings.

Self-Esteem, Public Esteem, and Therapeutic Change: Evidence

What factors seem to be responsible for the attainment of popularity in therapy groups? Three variables, which did not themselves correlate with outcome, correlated significantly with popularity: 1. Previous self-disclosure.76 2. Interpersonal compatibility:77 individuals who (perhaps fortuitously) have interpersonal needs that happen to blend well with those of the other group members become popular in the group. 3. Other sociometric measures; group members who were often chosen as leisure companions and worked well with colleagues became popular in the group. A clinical study of the most popular and least popular members revealed that popular members tended to be young, well-educated, intelligent, and introspective. They filled the leadership vacuum that occurs early in the group when the therapist declines to assume the traditional leader role. Members who are popular and influential in therapy groups have a higher likelihood of changing. They attain popularity and influence in the group by virtue of their active participation, self-disclosure, self-exploration, emotional expression, nondefensiveness, leadership, interest in others, and support of the group. It is important to note that the individual who adheres to the group norms not only is rewarded by increased public esteem within the group but also uses those same social skills to deal more effectively with interpersonal problems outside the group. Thus, increased popularity in the group acts therapeutically in two ways: by augmenting self-esteem and by reinforcing adaptive social skills.

GROUP COHESIVENESS

What is cohesiveness and how does it influence therapeutic outcome? The short answer is that cohesiveness is the group therapy analogue to relationship in individual therapy. In this book, cohesiveness is broadly defined as the result of all the forces acting on all the members such that they remain in the group,14 or, more simply, the attractiveness of a group for its members.15 Members of a cohesive group feel warmth and comfort in the group and a sense of belongingness; they value the group and feel in turn that they are valued, accepted, and supported by other members. I 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, 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.

Dealing With Your Own Reactions to Problematic Behaviors

When group members exhibit what you consider to be problematic behavior, examine your own desire to respond with strong feelings. Your own responses—be they feelings, thoughts, or observations—are often the most powerful resource at your disposal in effectively handling problematic behaviors. One rationale for group leaders to experience their own group therapy is that this kind of self-exploration increases the chances that they will gain awareness of their own blind spots and potential vulnerabilities.

Modeling

When you lead a group, you set the tone and shape the norms by the attitudes and behaviors you model in the group. It is important to state your own expectations for the group openly during the first session and to model interpersonal honesty, respect, and spontaneity. With regard to empathy—both cognitive and affective—you can create a therapeutic situation by being able to see and understand the world from the internal vantage point of the members. Another key characteristic is your sensitivity in attending and responding not only to what is said but also to the subtle messages conveyed beyond words.

MECHANISM OF ACTION

therapy, Rogers states that when the conditions of an ideal therapist-client relationship exist, the following characteristic process is set into motion: 1. The client is increasingly free in expressing his feelings. 2. He begins to test reality and to become more discriminatory in his feelings and perceptions of his environment, his self, other persons, and his experiences. 3. He increasingly becomes aware of the incongruity between his experiences and his concept of self. 4. He also becomes aware of feelings that have been previously denied or distorted in awareness. 5. His concept of self, which now includes previously distorted or denied aspects, becomes more congruent with his experience. 6. He becomes increasingly able to experience, without threat, the therapist's unconditional positive regard and to feel an unconditional positive self-regard. 7. He increasingly experiences himself as the focus of evaluation of the nature and worth of an object or experience. 8. He reacts to experience less in terms of his perception of others' evaluation of him and more in terms of its effectiveness in enhancing his own development. Group members' acceptance of self and acceptance of other members are interdependent; not only is self-acceptance basically dependent on acceptance by others, but acceptance of others is fully possible only after one can accept oneself. This principle is supported by both clinical wisdom and research. In my experience, all individuals seeking assistance from a mental health professional have in common two paramount difficulties: (1) establishing and maintaining meaningful interpersonal relationships, and (2) maintaining a sense of personal worth (self-esteem). Self-esteem and public esteem are highly interdependent.67 Self-esteem refers to an individual's evaluation of what he or she is really worth, and is indissolubly linked to that person's experiences in prior social relationships. The influence of public esteem—that is, the group's evaluation—on an individual depends on several factors: how important the person feels the group to be; the frequency and specificity of the group's communications to the person about that public esteem; and the salience to the person of the traits in question. A far more common occurrence in a psychotherapy group is a discrepancy in the opposite direction: the group's evaluation of a member is higher than the member's self-evaluation.