Review of Yalom, Theory and Practice of Group Psychotherapy

As a preeminent theorist of group psychotherapy, Yalom must be taken seriously. This ponderous tome rightly is regarded as one of the essential treatises in the field. It shares this distinction with Yalom’s other seminal work on existential psychotherapy (though at first glance it is difficult to discern a connection between his interests in these two very different fields). Yalom’s basic project is to analyze the structure of group dynamics. He examines the entire life cycle of the group, from formation to dissolution. He considers the nature, role and function of the group leader. He discusses the ways in which groups go awry. All of this is interesting and useful information.

Yet, there still is considerable cause for pause. Yalom speaks authoritatively, using a hyper-positivistic tone that implies he invented the concept of group psychotherapy, or that he is the font from which flows all knowledge in the field. For example, he gives only one throw-away reference (at p. 193) to the precedential work of Wilfred Bion, an important figure in the development of group theory. (1) Yalom asks no questions, pretends there are no uncertainties or confusing issues, and brooks no dissent. He ignores what I think is the most important issue about group therapy, which is: how effective is group therapy in treating psychopathology, as opposed to individual therapy?  This in turn raises an even more problematic issue, which is: what is the empirical status of group psychotherapy as an empirically-supported therapy (EST), to begin with?  Since this latter point lies at the heart of the puzzle, it is what I will address for the remainder of this essay.

One of the most engaging controversies in contemporary clinical psychology is the conflict between the paradigms of psychodynamic psychotherapy versus other forms of intervention such as RBT, the efficacy of which can be established using randomized controlled trial (RCT) methodology, Western et al. (2004). With EST methods, patients are pre-screened to minimize the possibility of differential diagnosis and confounding variables; treatments are “manualized” and a series of standardized treatment procedures is established; treatments are brief, to minimize the possibility of attrition and acclimatization; and outcome assessment focuses on symptom relief. Use of EST methods is fortified by the pragmatics of DSM-IV diagnosis and practical concerns such as insurance company reimbursement.

Defenders of psychodynamic approaches argue, on the other hand, that psychopathology is not malleable; that most patients are comorbid for any number of different Axis I disorders; that Axis I disorders typically imply Axis II issues; and that experimental, “scientific” methods cannot be generalized or extrapolated to clinical contexts where professional judgment is more important than following a pre-defined manual of standard procedures.

An example of the conflict between the two (discussed by Western et al.) is the use of CBT versus interpersonal therapy (IPT) for short-term depression. One study found that positive outcomes were associated with the extent to which the treatment was modeled on IPT. A second competing study found that the empirical prototype of CBT was more effective. More general issues include whether the elements of efficacious treatment are dissociable (and hence subject to dismantling) to begin with; and the effect of what can only be characterized as pre-selection of which treatments to test.

Western et al. conclude that in order to reconcile these competing issues, researchers (and clinicians) must “triangulate” their conclusions using “multiple methods.”  This is not particularly helpful (in the same way that “multi-modal” therapy is not a useful therapeutic modality).

Although they do not discuss it, Western et al. raise an interesting issue, which is, just exactly what is the status of group therapy as an EST?  The answer is that it depends on what one means by “group therapy.”  If the group is characterized as a “cognitive-behavioral therapy group” (GCBT), then it can be evaluated as an EST, Ingen et al. (2009). An example might be a 12-step program, which follows a specific protocol and results in outcomes that can be clearly defined and evaluated.

On the other hand, if the group is characterized as more psychodynamic in nature, then the EST schematic makes less sense. An example might be a cancer support group, Coyne et al. (2007). Such a group is “supportive-expressive” and characterized by its cathartic or confessional elements. It veers more towards personal insight rather than the cure of any specific psychopathology (or, at least, elimination or reduction of its symptoms).

There does not appear to be a clear-cut way to distinguish between the two, and group theorists nervously equivocate between them. An example is Barlow et al. (2006): “Still, some difficulties and dilemmas exist. Whether labeled empirically supported treatment (EST), or evidence-based treatment (EBT) … , or empirically validated treatments (EVT) … , it is safe to say both individual and group psychotherapy have entered the age of accountability.”  These sorts of mindless nostrums are too vague and general to be useful.

Further evidence of confusion is found in the deliberations of professional bodies. For example in 2004, a Commission on Psychotherapy by Psychiatrists requested that the American Psychiatric Association’s Council on research designate psycho-dynamic psychotherapy as an evidence-based psychotherapy. The Commission on Psychotherapy specifically included not only systematized individual psychotherapy, but also any form of group psychotherapy claiming to be psychoanalytic or psychodynamic, Gerber et al. (2006). The Council declined to do so, stating there currently is not enough evidence for such a claim and that more appropriately designed clinical trials were necessary.

Yalom does not address any of these issues, nor does he consider their implications. From a theory standpoint, though, they are fundamental. Yalom’s treatise best is regarded simply as a book about groups per se. It does not aspire to a higher level of analysis, which would involve a consideration of why group therapy is more effective in some contexts than individual therapy, or the issue of demonstrating its effectiveness, as I have outlined here. To deal properly with these issues Yalom would have to devise (and implement) specific experiments to discriminate between the two.  He also would have to consider the nature of what might count as a good explanation for any observed difference (and I assume a difference exists, otherwise there would be no call for a separate discipline called “group therapy”).

Endnote

(1) Bion held that groups have three basic emotional states: (1) “fight-or-flight,” which is characterized by sympathetic nervous system effects such as fear, hostility or aggressiveness; (2) “pairing,” which is a kind of reciprocal interaction characterized by anticipation, optimism and hope for a favorable outcome; and (3) dependence, which is characterized by a feeling of helplessness.  When a group adopts one of these stances, it interferes with the group’s purpose.  It is up to the group leader to interpret these dynamics, in order for there to be effective group work.  It would have been interesting and useful for Yalom to delve into his theories, and those of others, if only in footnotes or an appendix.  A presentation based solely on theory alone would not implement Yalom’s objectives.  It equally is true though that he may have veered slightly off the mark and become somewhat imbalanced in his exposition of practice versus theory.

References

Barlow, S. & Burlingame, G. (2006). “Essential Theory, Processes, and Procedures for Successful Group Psychotherapy: Group Cohesion as Exemplar.”  J. Contemp. Psychother. 36, 107 – 112.

Bion, W. (1991). Experiences in Groups; and other papers. New York, NY: Routledge.

Coyne, J., Stefanek, M. & Palmer, S. (2007). “Psychotherapy and Survival in Cancer: The Conflict Between Hope and Evidence.”  Psychological Bulletin, 133(3), 367 – 394.

Gerber, A., Kocsis, J., Milrod, B. & Roose, S. (2006). “Assessing the Quality of Randomized Controlled Trials of Psychodynamic Psychotherapy.”  J. American Psychoanalytic Ass’n 54, 1307 – 1312.

Ingen, D. & Novicki, D. (2009). “An Effectiveness Study of Group Therapy for Anxiety Disorders.”  Int’l J. of Group Psychotherapy, 59(2), 243 – 251.

Western, D., Novotny, C. & Thompson-Brenner, H. (2004). “The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and Reporting in Controlled Clinical Trials.”  Psychological Bulletin, 130(4), 631 – 663.

Yalom, I. (2005). Theory and Practice of Group Psychotherapy. New York, NY: Basic Books.

Yalom, I. (1980). Existential Psychotherapy. New York, NY: Basic Books.