Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=hpsi20

Psychoanalytic InquiryA Topical Journal for Mental Health Professionals

ISSN: 0735-1690 (Print) 1940-9133 (Online) Journal homepage: http://www.tandfonline.com/loi/hpsi20

The Evidence-Based Group Psychotherapist

Molyn Leszcz

To cite this article: Molyn Leszcz (2018) The Evidence-Based Group Psychotherapist,Psychoanalytic Inquiry, 38:4, 285-298, DOI: 10.1080/07351690.2018.1444853

To link to this article: https://doi.org/10.1080/07351690.2018.1444853

Published online: 21 May 2018.

Submit your article to this journal

View related articles

View Crossmark data

The Evidence-Based Group PsychotherapistMolyn Leszcz, MD, FRCPC, CGP, DFAGPA

ABSTRACTGrowing attention is appropriately afforded to the importance of practicinggroup psychotherapy in an evidence-based fashion. Pressures with regardto accountability, efficiency, and effectiveness make this an imperative incontemporary psychotherapy. This article illustrates and operationalizesfactors that contribute to enhanced group psychotherapist effectiveness;identifies approaches that maximize therapeutic opportunities within theclient-therapist relationship in the here and now of the group therapysetting; and illustrates the principles of therapeutic metacommunicationwithin the therapeutic relationship and explores therapist use of self andjudicious therapist transparency. An evidence-informed approach guidesthese articulations and the article illustrates these principles with a clinicalvignette and discussion

In the contemporary practice of our work, it is incumbent upon all practitioners to aspire to be anevidence-based practitioner, blending the art and science of our work together. As noted by Traceyet al. (2014), experience alone does not confer effectiveness and therapists must engage specificfeedback and specific training to achieve and sustain their effectiveness. We are encouraged to bethoughtfully deliberate in this approach (Chow et al., 2015). This includes being attuned to theresearch that identifies elements and factors that contribute to enhanced therapist effectiveness;reviewing challenging cases; reflecting on past sessions and reflecting on what to do in futuresessions—all guided by an understanding of the scientific literature. Throughout, emphasis is placedon the recognition and utilization of evidence-supported group therapist interventions blended withaccrued clinical wisdom. Theory teaches us where to head therapeutically. Technique teaches uswhat to do once we arrive there. These principles are relevant both for experienced practitioners andare fundamental to the training of the next generation of group therapists.

There is consistent meta-analytic and literature review evidence that the psychotherapies, as a whole,are effective and that group therapy, in essence, is as effective as individual therapy (Burlingame et al.,2013). Yet, in contemporary mental health care, it appears that the psychotherapies have been undersold,notwithstanding their robust effectiveness on symptoms and global functioning and the capacity toimpact the brain through the mind (Weissman, 2013). That is the good news. The less good news is that,although there is fundamental equivalence across therapies andmodels, there is no such equivalence withregard to therapists (Norcross andWampold, 2011; Baldwin, 2013). Beyond client characteristics, in fact,it is the therapist and the therapeutic relationship that most impacts outcome. The therapist’s capacity toachieve and sustain an emotional bond; build and maintain a human context; enhance self-efficacy onthe part of the client and create an adaptive, accessible, and culturally resonant explanation for the client’score concerns are cornerstones of our effectiveness (Laska et al., 2014). This summary, in essence, reflectson the common factors that underpin our work—yet common factors, albeit readily understood are notso readily employed and maximized (Wampold, 2001).

CONTACT Molyn Leszcz, MD, FRCPC, CGP, DFAGPA m.leszcz@utoronto.ca University of Toronto Department of Psychiatry,925-600 University Avenue, Toronto, ON M5G 1X5, Canada.Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/hpsi.Copyright © Melvin Bornstein, Joseph Lichtenberg, Donald Silver

PSYCHOANALYTIC INQUIRY2018, VOL. 38, NO. 4, 285–298https://doi.org/10.1080/07351690.2018.1444853

Two naturalistic studies illustrate the significant variability in therapist effectiveness. Although thesestudies are based upon individual treatment, there is no reason to expect that the findings would bedifferent for group therapists. Okiishi and colleagues (2006) studied 71 therapists working in a range ofdifferent models treating over 6,000 clients with a range of familiar clinical presentations in a collegecounseling center using the OQ-45 (Lambert et al., 2010) as an outcome measure. The authors notedthat gender, age, experience, or model did not distinguish effective from ineffective therapists. Therewas, however, a notable discrepancy between the top 10% of therapists based upon OQ-45 outcome andthe bottom 10%. Those fortunate enough to see one of the top 10% therapists, had a 44% recovery rateand only 5% deterioration rate, whereas those seeing the bottom 10% of therapists conferred only a 28%chance of recovery and an 11% deterioration rate. Another way to look at this arithmetically is that aclient was nine times more likely to improve than deteriorate seeing a top-tier therapist and barely twiceas likely to improve seeing a bottom-tier therapist.

A subsequent study by Kraus (Kraus et al., 2011), looking at almost 700 therapists providing 16session therapy—again employing a range of models to nearly 7,000 clients and using the treatmentoutcome package, noted that effective therapists achieved positive effect sizes in the range of 1.00–1.52, which are very significant, whereas ineffective therapists had negative effect size impacts of asimilar magnitude underscoring the great variability of therapists. The authors articulated graveconcern about the public health impact of the provision of poor therapy. These impacts includepotentially avoidable client suffering and distress; elongated and hence more costly treatments;reduced access; and demoralized providers and discouraged clients. Part of how our field canrespond is to identify the key elements that are at the cornerstone of group therapist effectivenessand aim to employ them deliberately and thoughtfully.

Achieving and sustaining group therapist effectiveness

Led by John Norcross and colleagues, the American Psychological Association established a taskforceexamining the elements that are most associated with improved clinical outcomes in individual,family, and group psychotherapy (Norcross and Wampold, 2011). They noted the following: There isstrong empirical support for the role of cohesion and the therapeutic alliance in promoting betteroutcomes and strong empirical support for the role of empathy. In this model, empathy is viewedmore than kindness and, in fact, it is a tailored in-depth understanding of the individual thatincludes both receptive and expressive empathic capacities, and the therapist’s adapting to andprivileging the client’s psychological position and patterns of attachment (Mallinckrodt and Jeong,2015). Additionally, there is strong support that outcomes are improved when therapists track whattheir clients are doing in treatment with both outcome and process measures providing feedback inan ongoing and accessible fashion to the provider (Slone et al., 2015).

Historically, consideration of being an evidence-based psychotherapist or group psychotherapisthas identified three distinct approaches (Leszcz and Kobos, 2008). The first approach is to use onlyempirically supported therapies (ESTs). This has often been criticized by practitioners because theexcellence of ESTs in identifying treatment efficacy often lacks relevance with regard to effectivenessin the naturalistic setting. A second approach is to be guided by clinical practice guidelines thatsynthesize scientific literature and consensus to provide evidence-supported guidance for practi-tioners with regard to implementation of effective treatment in ways that augment clinical judgment(Bernard et al., 2008; Leszcz and Kobos, 2008; Burlingame et al., 2013). The third approach is togather practice-based evidence through the ongoing monitoring of clinical impact and processeswithin treatment, utilizing feedback to reinforce or realign treatment approaches as is required(Hannan et al., 2005; Lambert et al., 2010). This article will expand upon the second approach.

286 M. LESZCZ

Group cohesion

Cohesion has been long identified as a core mechanism of group therapeutic action (Yalom andLeszcz, 2005). It plays an essential role, in and of itself, with regard to the emotional value ofbelonging and the impact of clinical presence. Cohesive groups create a healing context(Wampold, 2001) and set the stage for the provision of an adaptive relational experience thatcan disconfirm the clients’ negative expectations and pathogenic beliefs about themselves (Leszczand Malat, 2012). In addition, cohesion is the platform upon which all other therapeutic factorsoperate. It is a ubiquitous mechanism that operates across all therapeutic interventions andorientations and appears to explain as much, if not more, client improvement than specificmechanisms of actions, models, or protocols (Burlingame et al., 2013). In understanding groupcohesion, it is important to recognize that cohesion involves both task effectiveness elements andbond elements and captures the comprehensive interplay of group and individual memberrelatedness across multiple dimensions: member-to-member, member-to-group, and member-to-leader. It encompasses both relationship structure and relationship quality. Studied in a varietyof ways, there is encouraging evidence for the utility of measures such as the group questionnaire(Krogel et al., 2013), which captures measurements of both positive bond; positive work and thepresence of negative relational factors.

Burlingame (Burlingame et al., 2011) described the positive and significant linear relationship ofcohesion with outcome and although the effect size appears to be small to moderate, the findings areconsistent and durable. Burlingame also noted that moderators that may enhance group cohesioninclude groups for clients of younger adult age, although there is certainly much evidence to supportthe role of group therapy in geriatric populations (Leszcz, 2009); a duration of treatment that runsover 12 sessions; a preferred group size of 5–9 members; an interpersonal focus that makes use of thegroup as an agent for change and not just as a setting for delivering an intervention; and a range ofspecific therapist actions. More detailed explication of cohesion building therapist actions will follow.As noted by Bernard et al. (2008), cohesive groups are linked to higher member self-disclosure;improved group tenure and participation and reduced dropouts. Cohesion and a sense of a belong-ing can buffer members during emotionally intense phases of the therapy and during interpersonalconflict with peers in the working phase of group therapy.

How does the evidence-based group therapist promote group cohesion? The American GroupPsychotherapy Association Guidelines (Bernard et al., 2008) and subsequent reviews (Burlingameet al., 2013) underscore the following principles in three core domains: use of group structure, natureof verbal interaction, and establishment of an effective emotional climate.

With regard to the use of group structure, evidence-based group therapists conduct pre-grouppreparation that sets treatment expectations; defines group rules and informs members of whatappropriate roles and skills are needed for effective group participation that, in turn, promote groupcohesion and maximize therapeutic opportunities. Pregroup preparation, ideally delivered by theactual group leader, may include didactic; psychoeducational, illustrative videos and experientialcomponents. Both general and client-tailored elements can be interwoven. In settings where preg-roup preparation cannot be done, alternative approaches to orient clients and structure the experi-ence in advance are helpful. These may include written handouts, a pregroup group orientation, andstructuring the group session to include an introduction at the start of each session as may berequired in an acute inpatient setting (Yalom and Leszcz, 2005). Related to this, the group leadershould establish clarity early on through direct illustration and psycho-education regarding impor-tant group processes that create a safer environment setting the stage for later work with regard toclient self-disclosure, risk taking and interpersonal feedback. A related principle is the considerationof group composition, balancing interpersonal and intergroup considerations when possible.Although group composition may feel like an inaccessible luxury in our current environment, thegroup therapist is encouraged to construct groups that reduce member isolation or a sense of beingdeviant to the group as a whole. Where possible, the aim should be to create balance with regard to

EVIDENCE-BASED GROUP PSYCHOTHERAPIST 287

interpersonal style; group experience, and capacity for engagement—good balance of membership inthese characteristics all foster improved cohesion.

With regard to verbal interaction, the group leader has an important role in offering observations,modeling feedback, clarifying, and reinforcing the key elements of effective interpersonal feedback.The following elements are associated with greater therapeutic effectiveness (Yalom and Leszcz,2005; Leszcz, 2014). Interpersonal feedback should emerge from collaboration on the client’srespective treatment goals. The sender should also be taking a self-disclosure risk and the groupshould explore both the sender’s and receiver’s experience of the feedback process. The group shouldbe supportive and reinforce risk taking, which is much more readily achieved if the feedback isneither judgmental nor inflammatory. Ideally, feedback is well paced with some positive to prefaceand precede the negative. Feedback is most effective when it focuses on observable behavior withinthe here and now with an emphasis on the mutative impact on contemporary relatedness rather thanhighly inferential genetic reconstructions. The sender invites the desired behavioral change asopposed to only offering a rebuke, again linked ideally to the individual’s treatment goals andencourages in turn the receiver’s responsibility for change without coercion.

The fifth principle relates to the timing and delivery of feedback, noting that more challengingfeedback or, for that matter, more high-risk client disclosures need to be synchronized with wherethe group and individuals are developmentally, regarding their capacity to tolerate and hear feedbackin the spirit in which it is intended. Shifting from vertical disclosure to horizontal or meta-disclosurein which the group member is invited to speak about their wishes, fear, and expectations regardingthe process of their disclosure, rather than providing more content material, may be an effective wayto maintain engagement while reducing the potential for overly intense and potentially triggering ortraumatizing feedback and disclosure.

With regard to establishing and maintaining an emotional climate, the group leader mustrecognize her important role with regard to maintaining a balanced level of affiliation and controlwithin the group. The leader’s recognition of countertransference and management of her ownemotional presence in the service of others is critically important and models the effective handlingof interpersonal conflict; protects against member scapegoating and contributes to a safe andinclusive environment. Finally, a primary focus of the group leader should be on facilitating groupmembers’ emotional expressiveness; the responsiveness to that expression and disclosure and theshared meaning derived from such expression. The effective group leader activates and attributesmeaning to experience in proper balance; conveys a sense of caring and warmth, in addition, ofcourse, to effecting the executive functions of the group leader with regard to the organization andimplementation of the group (Bernard et al., 2008).

Empathy

It is useful to think about empathy in relation to therapist effectiveness as it reflects the dualelements. The first aspect is our capacity to understand and employ models of understanding thatconvey to our clients a deep appreciation for their core concerns; a nonshaming and nonblamingconceptualization; and our willingness to engage with them meaningfully. This encompasses thereceptive aspects of empathy—our articulated and demonstrated understanding. The second aspectof empathy reflects the expressive components in the form of our capacity to communicate thatunderstanding in ways that are maximally useful to our client. We spend much time in trainingdeveloping the former and relatively little with regard to the latter, yet both are of great importance.

Being guided by an understanding of the evolution of psychotherapy is helpful in advancing ourunderstanding of both domains of empathy. Stephen Mitchell (1993), in his classic text underscoredthe importance of the therapist being able to move beyond understanding alone to a position ofbeing shaped by the required interaction to create with the client, the developmentally necessary,new and contrasting relational experience. As we have moved from a one-person psychology to atwo-person psychology and a greater focus on deficits, the self and relationships rather than internal

288 M. LESZCZ

conflicts, it becomes more and more essential that therapists take responsibility to foster with theclient and group members in a co-constructed fashion. A therapeutic environment in which a newrelationship is created that emphasizes facilitation and growth, rather than a recreation of priorrelationships that may inadvertently generate impasse or failure. How the therapist uses herself inthis arena is critically important and will be discussed in more detail. Stretching the point to make apoint on this front, the empathic therapist recognizes that treatment will either disconfirm orreconfirm prior pathogenic beliefs the individual holds about himself in relation to the world.This demands a persistently reflective therapist posture and the capacity to anticipate a synthesisof repetitive intersubjective conjunctions and intersubjective disjunctions. How we work within thetherapeutic relationship is the essence of our effectiveness (Hill and Knox, 2009) and our capacity tounderstand and process the therapeutic encounter through the use of therapist self; countertrans-ference analysis; and meta-communication are critically important. We are cautioned, as well, to beever mindful of subtle or overt expressions of power, hostility or rejection in our modes ofengagement and feedback.

Empathy and therapeutic focus

Therapeutic focus or transference-related measures have become an increasing focus of contempor-ary study. This reflects the increasing awareness that greater precision in formulation contributes toimproved outcome by increasing the congruence of therapeutic interventions and the articulation ofempathy (Hoglend, 2014). There is particularly strong correlation of transference work and outcome,especially for clients with difficult interpersonal relationships and prominent character pathology.

Our precision with regard to empathic understanding helps us move into genuine empathicengagement with our clients beyond kindness alone and enhances our therapeutic attunement.Contemporary psychotherapy models often demonstrate an interface of dynamic and cognitivepsychological understanding with a focus on transference and schema-related work (Leszcz, 2014).An overarching synthesis underscores certain linkages that emphasize the relationship between theindividual’s pathogenic beliefs shaped by early life experience and the interpersonal articulation ofrelational expectations based upon those pathogenic beliefs. This is a nonlinear model but, rather, acircular model, in which the individual recreates maladaptive transaction cycles while hoping againsthope for therapeutic experiences that will disconfirm and challenge fundamental beliefs one holdsabout oneself. One can see elements of this in Strupp and Binder’s (1984) misconstrual-misconstruc-tion sequence; Luborsky’s core conflictual relationship theme model (Luborsky and Crits-Christoph,1998) and Wachtel’s model of cyclical psychodynamics (Wachtel, 2011). A related model that theauthor has found helpful, both in clinical practice and in training, is the control mastery theory, alsoknown as the plan formulation model, emerging from the work of the Mount Zion PsychoanalyticGroup and captured well by Joseph Weiss (1993) in his text, How Psychotherapy Works: Process andTechnique. This model lends itself well to the interpersonal arena of group therapy.

In essence, the plan formulation model puts into operation the client’s plan for treatment, whichis understood as the manner in which the individual will work in psychotherapy to seek safety todisconfirm pathogenic beliefs, overcome obstructions to growth and development, and achieve thegoals of treatment. This is a nonpartisan model and compatible with a range of different psycho-logical formulations, but at its heart identifies that our clients are seeking growth and it is incumbentupon us to respect their best adaptive efforts. This model is very much compatible and aligned witheffective transference-focused therapy (Hoglend, 2014) and gives shape to the structure of receptivetherapist empathy. The more our therapeutic interventions are aligned with the client’s plan,whether it is focused on work inside the therapeutic relationship or external to the therapeuticrelationship, the more evidence emerges for increasing client self-awareness, leading to greater accessto emotion, appropriate self-reference and genetic anamnesis. Plan-congruent interventions thatdisconfirm client’s pathogenic beliefs create a progressive therapeutic emboldenment on the client’spart and improve access to genetic material that has previously been covert.

EVIDENCE-BASED GROUP PSYCHOTHERAPIST 289

Framed another way, we can think of the plan formulation as a treatment roadmap consisting ofthe following elements. First are the client’s goals, whether they relate to developmental tasks,relatedness, or growth (Weiss, 1993; Leszcz and Malat, 2012). These are obstructed by pathogenicbeliefs that emerge from early life experience. As noted by Sammet et al. (2007), the pathogenicbeliefs focus on the client’s self-doubt; mistrust, or doubt of others; difficulties with anger andassertiveness; the fear of closeness; guilt regarding growth or development and success; and guilt andresponsibility for others. The individual incorporates, early in life, the conviction that goal attain-ment is dangerous and results in rejection, loss, or crushing rebuke. The third element of the planformulation model involves the way in which the client will test within treatment these pathogenicbeliefs in the form of transference tests that are articulated in interpersonal or relational terms. Thesetake one of two shapes. The first is more traditional and involves the displacement of past ontopresent. This is a familiar form of transference in which the past is projected into the present. Lesscommon, but more difficult, are situations in which the past becomes projected into the present butnot by displacement but, rather, by a form of mastery by inversion. In the first instance, anindividual fearing criticism or rejection for assertion/expression will bring that into the dynamicof a treatment, manifesting avoidance or inhibition and expecting shaming or rejection. In thesecond instance—mastery by inversion—the individual fearing criticism for the pursuit of emotionaland psychological needs will, instead, identify unconsciously with her aggressor of early years andbecome attacking and critical of others as a manifestation of the difficulty with assertion/expression.This is a particularly prominent dynamic in individuals who have been traumatized or mistreated.They master their own vulnerability to being abused by becoming abusive to others. Unchecked,what gets recruited is attack, rejection, hostility, and a reconfirmation that engagement with others isunsafe. Throughout, our clients seek disconfirmation of pathogenic beliefs and relational therapeuticsafety, even as the interpersonal processes they employ recruit responses that they dread. Bothinsight and importantly relational experience are essential in altering these maladaptive transactioncycles and promoting an earned and lived relational insight and experience that the client is thenable to rely on and draw upon to challenge the obstructions that interfere with their growth anddevelopment. In supervising residents and trainees, it can be quite helpful, even essential, to haveeach client formulated in this fashion. Each client’s respective roadmap is articulated prior totreatment actually beginning, in a coconstructed fashion, as a clinical focus for treatment. Thisfosters greater therapeutic attunement and increases the likelihood of therapeutic interventions thatinterrupt, rather than reinforce, maladaptive transaction cycles.

Many contemporary approaches in group psychotherapy create a natural and effective platformfor the operationalizing of these principles (Leszcz and Malat, 2012; Yalom and Leszcz, 2005). Thenature of the client’s transference tests and their articulation within the therapeutic encounter alignvery readily with utilizing the group as a social microcosm with its emphasis on the here and nowdynamic and interpersonal interaction. The illumination of the transference tests and the pathogenicbeliefs that reside beneath the manifest interactional processes are at the heart of much group workand provides an opportunity for repair, healing, and, importantly, interpersonal learning.Interpersonal learning then sets the stage for an adaptive spiral promoting the progression frominsight and behavioral change in the group to change outside of the group in the client’s life at large.

The cornerstone concept of the group functioning as a corrective emotional experience under-scores the importance of creating therapeutic opportunity in the face of therapeutic illumination thatendorses new behaviors, putting self-understanding into operation as improved interpersonal rela-tionships and communication. The group members’ and the group leaders’ capacity to reflect oninterpersonal communication, and process its meaning as it relates to the group as a whole and tothe individuals at the center of the interaction, is an important part of therapeutic effectiveness.

In the spirit of maintaining empathic attunement, it is helpful to have models of understandinginterpersonal impact and the ways in which interpersonal intent and impact can become misaligned.Donald Kiesler’s (1996) work on the impact message and the interpersonal circumplex are instruc-tive in this regard. Understanding interpersonal processes facilitates the therapist identifying and

290 M. LESZCZ

metabolizing the client’s interpersonal impact in a process of hooking and unhooking ever mindfulof what we as therapists bring to the mix regarding our own cognitive and interpersonal processes.Kiesler’s writing illuminates a model for identifying and working with countertransference throughthe interpersonal lens. The therapist is encouraged to identify direct feelings, i.e., “when I am withthis person he makes me feel certain ways;” second, the therapist identifies action tendencies withregard to behaviors that feel as though they are being recruited in the therapist or other members ofthe group; and third, the therapist is able to identify the evoking message that recruits and elicits thisresponse. Attention to one’s reverie and fantasy sets the stage for deeper examination of counter-transference as a way of understanding how the client recreates in his contemporary world anopportunity for disconfirmation or reconfirmation of core pathogenic beliefs.

Allied with an appreciation of interpersonal impact is an understanding of interpersonal pulls.Interpersonal communication reflects verbal, nonverbal, and paraverbal elements, both manifest andmore subtle (Yalom and Leszcz, 2005). All interpersonal behavior can be understood as an expres-sion and amalgam of two interpersonal vectors. See Figure 1.

The first vector is the vector of agency or power running the spectrum from dominant tosubmissive positions. The second domain or vector is that of affiliation running the spectrumfrom hostile and cold at one pole to warm and friendly at the other pole. Interpersonal behaviorcan be an amalgam of these two positions and two vectors, such that an individual can be principallydominant in their interpersonal relatedness, hostile-dominant, hostile, or hostile-submissive.Similarly, an individual can relate principally in a friendly-dominant way, a friendly way, afriendly-submissive way, or in a submissive fashion. Why is this important? Because the initialinterpersonal impact of these interpersonal processes follows the laws of interpersonal complemen-tarity (Kiesler, 1996) in which interpersonal behavior on the agency axis recruits the inverse in theother. Hence, a dominant interpersonal posture will recruit an initial response of submissiveness.The opposite is true, as well. Submissive and subordinate interpersonal postures recruit dominationresponses. Along the vector of affiliation, however, what is recruited is concordance such that hostilebehavior recruits hostile behavioral responses. These are not locked in permanently but certainly arethe initial interpersonal processes.

Hence awareness of the pulls and hooks allows the therapist to maximize reflective awareness andrespond in ways that do not fuel the maladaptive transaction loop, but provide an opportunitythrough expressive empathic communication to engage a healthier, more effective interpersonalsequence. (See the detailed clinical illustration to follow for an illumination of these principles.) Theinterpersonal hooking is the way in which the client’s pathogenic beliefs shape the environmental

Figure 1. Octant complementary “pulls” of Kiesler’s interpersonal circle (1996).

EVIDENCE-BASED GROUP PSYCHOTHERAPIST 291

response that create maladaptive transaction cycles that, if unchecked, reinforce pathogenic beliefs.Alternately and ideally, we seek to identify the risk of a maladaptive transaction cycle to be able toaddress it through illumination and feedback and create a more virtuous and adaptive transactioncycle. Getting hooked is not the problem. In fact, if one is not getting hooked, it is a reflection of notbeing close enough to the therapeutic action to be of use. The key is to be able to find a way tometabolize one’s reaction and move into expressive empathy through metacommunication andprocessing to be able to turn the cycle into a virtuous one. At the heart of the maladaptivetransaction cycle is the concept of circular causality. The client’s attempt at solution becomes theproblem. The defense is not the answer. The defense is the problem.

The good news behind this understanding is that the same forces that contribute to a negativeloop can be mitigated and create a constructive loop. Hence the client is always on the cusp in grouptherapy of a self-fulfilling or self-defeating sequence. Hill and Knox (2009) identified this sequence ofconjunction and disjunction as the “tear and repair” process in psychotherapy (p. 13), underscoringthe importance of understanding and maximizing the power of the therapeutic relationship. Effectivetherapists work in the immediate and in the here and now to address the necessary and essentialproblems that emerge in the therapeutic relationship. They acknowledge their role, explore, shareattribution, validate, negotiate, and respond with flexibility rather than rigidity (Bennett et al., 2006).

Working with countertransference

As a preface to articulating the principles of the expressive component of therapist empathy, it isimportant to address the value of countertransference. In this framework, countertransference isviewed as important clinical data that informs the therapist about important information regardingthe client or potentially about the therapist herself. We can think of countertransference as to fallinginto two broad domains—objective and subjective—but always viewed in some fashion as a two-person field or joint creation (Kiesler, 2001). The emergence and recognition of countertransferenceexpands our therapeutic capacity, rather than manifesting as a therapist error. Throughout, thetherapist recognizes that psychotherapy is a fiduciary relationship. The group leader operates withincertain constraints in the utilization of countertransference within the therapeutic relationship,always ensuring the duty to advance the therapeutic process even when powerful emotions becomeactivated in the group therapist.

As noted, we can conceive of countertransference as falling into subjective and objective domains.Subjective countertransference is often more a reflection of what the therapist is experiencing basedupon the therapist’s current or historic circumstances. It may be what the therapist habitually bringsinto the treatment, reflecting the therapist’s earlier or concurrent experiences that get reactivatedwithin the treatment environment. Objective countertransference reflects more on the client. It is acommentary about what the client specifically generates within the therapist via projection; projec-tive identification or interpersonal processes and what the client habitually generates in terms ofother people’s responses to him. These are not always clearly demarcated and there is often aninterface between the objective and subjective countertransference. The key is to look at counter-transference as data and engage it with the spirit of inquiry without blame. A comprehensive reviewof countertransference in psychotherapy underscores (Hayes et al., 2011) that unaddressed counter-transference clearly correlates with negative outcomes but when worked through, significantly iscorrelated with positive outcomes and enhanced therapist effectiveness. Our growing awareness ofthe way in which certain countertransferential responses are objective reflections of our clients thatarise consistently and independent of our theoretical models (Colli and Ferri, 2015) contribute to ourwillingness to look at countertransference openly with less hesitation and fear of judgment fromcolleagues or supervisors.

The management of countertransference is an essential component of effective therapist work. Asnoted by Gelso and Hayes (Gelso, 2007; Hayes et al., 2011), the cornerstones of the effectivemanagement of countertransference involve therapist self-awareness and groundedness; the

292 M. LESZCZ

therapist’s ability to calm oneself and maintain a sense of self-integration distinguishing what is selfand what is other; and being able to maximize reflective capacity on experiences that get generatedwithin the therapist emerging from the treatment. The capacity to modulate anxiety is criticallyimportant as well as is the therapist’s ability to conceptualize what is underway, being proximatesufficiently to be hooked and have the capacity then to get unhooked.

Expressive dimensions of empathy

Two key elements comprise expressive empathic capacity. These include therapeutic metacommunica-tion and the judicious use of self. Kiesler (1996) described metacommunication as “any instance inwhich a therapist provides to the client verbal feedback that targets the central, recurrent and thematicrelationship issues occurring between them in the therapy sessions” (p. 29). This is predicated uponfirst being hooked and then getting unhooked and processing the interaction and relationship.Therapeutic metacommunication is communication about interaction and communication. It is thesurgical skill of the group therapist and one’s capacity to communicate unpalatable reactions inpalatable, non-shaming, non-blaming fashion is critically important. Guidelines that are helpful fortherapists include the following: Align your intention with your actual impact to maximize theusefulness to the client; process your feedback through the initial therapeutic alliance and theconvergence with the client about their goals of treatment; identify the impact message and decon-struct it so that feedback can be provided at various levels of inference. Oftentimes, therapists hesitateto provide feedback because of an inability to address this at relatively lower levels of inference thatcreate more therapeutic maneuverability for the client and in essence do not push the client into acorner. Recognize that the tendency to get hooked precedes an opportunity to get unhooked. In otherwords, a pull toward submission or a pull toward hostility should not result in either domination orhostility, but rather finding a third route to identify the interpersonal processes in a transparent andmaximally effective fashion. Effective therapeutic metacommunication involves the group therapistbringing feedback into the here and now, blending challenge with support and ideally coming to thisfrom a position of lower affective intensity rather than greater affective intensity. Throughout, thetherapist is encouraged to manifest positive regard, blending tact with authenticity.

Therapist transparency and self-disclosure

Therapists become more transparent as they gain more experience and recognize the great value ofjudicious self-disclosure but are often reluctant to encourage junior colleagues to do so for fear ofcreating boundary tensions and a slippery slope into nontherapeutic and in effective communication(Leszcz, 2009). They also recognize that it is impossible not to be self-disclosing; rather it is a matterof how to use that self-disclosure in a maximally therapeutic fashion. Some guidelines that are of use(Leszcz, 2009; Wachtel, 2011) include the principles that disclosure and transparency should alwaysbe aligned with the treatment goals. The therapist must first be able to reflect and ascertain, afterprocessing and metabolizing one’s reactions, that the feedback is likely to be useful and constructive.It is essential to ensure that therapist self-disclosure is not emerging from unprocessed counter-transferential reactions that aim to either protect therapist’s sense of self, self-esteem, power ormaintain a relational hierarchy.

Transparency is a tool and not an end in and of itself, and is safest when it is focused on the hereand now, providing an ahistorical, rather than personal or historical, elaboration. Without doubt,there is a great risk of damage to the treatment with unchecked therapist hostility. Within the group,therapist transparency also provides essential modeling and norm setting and encourages others inthe group to take risks in a spirit that is demonstrated by the group leader.

McCullough (2006), writing about disciplined personal therapist involvement, highlighted theimportance of feedback as a way of enhancing client self-efficacy and restoring for many of ourclients a sense of cause and effect with regard to understanding how they affect their environment

EVIDENCE-BASED GROUP PSYCHOTHERAPIST 293

for better or for worse. Throughout, we need to protect the frame of treatment and the therapeuticboundaries, sensitive to timing and stage of treatment with regard to our feedback. Do not assumeone’ s impact; rather the group leader should process with the group members the impact of her self-disclosure recognizing that the same therapist behavior or communication can have differentialimpact at different stages of treatment and for different clients at different times (Tritt et al., 2015).

Clinical illustration

A clinical illustration from a recent session of an open-ended therapy group of four men and fourwomen can serve to bring these principles to greater light. This vignette and discussion have beendescribed elsewhere, as well (Leszcz, 2014). The group members permit use of clinical examples withmy commitment to disguise individual identifying characteristics.

Melanie, a 42-year-old single woman working as an English tutor, begins the session. She seeksgroup therapy to deal with chronic issues of depression, poor self-esteem, poor relational choices,substance abuse, and significant feelings of shame. Another key member is Noah, a 45-year-oldmarried businessman. He seeks group therapy to deal with issues of interpersonal isolation andchronic relational and marital dissatisfaction, feeling neglected and unrecognized for his talents andabilities. Melanie, relatively new to the group, began this session in obvious emotional distress. Shewas grateful to be in the group but self-critical for having made little use of it to date. She enteredtoday’s meeting determined to open up to the group about her core concerns. She had seen others inthe group do this over time to good effect and she was unhappy going home repeatedly feeling thatshe had barely scratched the surface.

Despite apprehension, Melanie described, in detail, her life-long struggle with poor self-esteemand self-worth. Growing up as an only child with a single mom, abandoned by her father, she alwayswondered about her self-worth, noting that she made choices that seemed to play to her vulner-abilities, engaging men who were exploitative and abusive. To deal with strong negative emotions,she abused marijuana and cocaine, resulting in significant financial debt, which in turn meant thatshe had to work incredibly long hours as a tutor to pay off her debts. This was a powerful revelation,even more notable as it was her first major disclosure and she held the group’s focus for a significantsegment of the meeting.

We processed with her the experience of the disclosure and provided feedback. Group memberswere spontaneous and forthcoming, supporting her self-disclosure and making similar self-disclo-sures about substance abuse, indebtedness, and their own history of poor choices. One groupmember commented how she could feel, palpably, the kind of shame that Melanie carried aroundthese behaviors and past choices, and wanted to reassure her that everyone could relate to her andthat the best way to deal with negative behaviors was to illuminate and tackle them with the supportof the group. The impact this had on Melanie was quite profound. She continued to cry, but nowwith some relief and acknowledged how grateful she was for the group’s support and care. Anothermember of the group noted how much respect she had for Melanie, directly challenging Melanie’sshame and anticipation of a judgmental or rejecting response when, in fact, she was not onlyidentified with; she was actually the object of admiration regarding her courage and openness.They added how much they appreciated having Melanie in the group and they looked forward tocontinuing to work with her.

Throughout, Noah sat seemingly disengaged. Others recognized the importance of Melanie’swork, but Noah did not say one word, evoking in the group leader substantial countertransference.Although we had worked on Noah’s narcissistic self-absorption and his tendency to seek from thegroup without giving to it, clearly, it had not impacted as intended, evident in Noah’s seemingdisinterest in Melanie at this pivotal moment. With the momentary kind of pause that groups oftenuse to shift foci, Noah jumped in, exclaiming he also had important things to address, describinganother round of difficulties with his wife’s lack of responsiveness toward him. In contrast to theearlier segment, in which people were literally leaning forward in their chairs, drawing as close as

294 M. LESZCZ

they could to Melanie, people listened politely without much evident engagement. The grouptherapist made a process inquiry asking the group to compare how they felt in the first part of themeeting with how they were feeling now. There was little response to that question, so the grouptherapist decided deliberately to move into a zone of greater therapist transparency and speak abouthis reaction to Noah.

It went something like this:

‘Noah, I am going to take a bit of a risk here and share with you something that I hope I can convey in a waythat you are able to hear. I hope you do not experience this as harsh, but I found myself finding it hard togenerate interest in what you were saying to the group, not because what you feel is not important to me—it isvery much so—but I was feeling disappointed that you had been silent throughout the meeting. I want to askyou how you felt about Melanie and what she had just brought to share to the group.

Noah acknowledged that it was important and he was supportive of her, but he added that hechose not to speak, waiting to talk about his own concerns. I noted that his lack of response toMelanie made it harder for me to respond to him. Perhaps the group’s subdued response to himreflected the same dynamic; a few heads nodded in agreement. I went on to describe to Noah howhis waiting for an opening to turn the group’s attention onto him, rather than responding toMelanie, was concerning. I linked this with his goals for entering the group with regard to improvinghis sense of connectedness to others and reducing his sense of marginalization in his own life. Iasked him to consider again the importance of reciprocity and that attention from others is not azero-sum game but, rather, a renewable resource: The more he gives to others, the more he will bereciprocated, unlike within the very competitive and narcissistic family of origin he described to us,in which care and support were, in fact, a zero sum. As he had shared earlier with us, growing up inthe family, it was the loudest and most demanding person who received whatever little bit ofattention that was available.

Noah acknowledged that my feedback hurt and wondered how long I had harbored that feeling. Ianswered I had been thinking about it throughout the meeting and spoke about it as soon as I wasclear how I could address it. He added that he valued our relationship and would think about thisfeedback, asking others what they thought. Jack, an older man in the group, commented that it wasincredibly useful feedback—he hoped Noah would be able to hear it. He wanted to give Noah similarfeedback but found no way to do so without being hurtful and he credited the therapist for finding away to do so, encouraging Noah to use this opportunity.

Noah seemed to take this in and Susan, a depressed and isolated middle-aged woman who grewup in an environment with great emotional deprivation and neglect, asked how I determined to saywhat I did. Was that technique or did it come from a genuine place in me? I responded that I felteverything I said, and would only say what I felt genuinely. Choosing to share it and trying to findthe best way to do so involved technique, but I felt connected emotionally to what I was saying. Iinquired what that feedback meant to her, adding that the capacity of caregivers to be authentic andreliable was enormously important in allowing her to feel safer. She needed to know that she couldtrust that the group and I were operating in a genuine way, rather than in a perfunctory fashion.

Discussion

The purpose of the vignette is to illustrate some of the key elements that make group therapy and thegroup therapist effective, building upon the evidence-based principles reviewed in this article. Theseelements include the following. Melanie is able to take the large risk that she does by virtue ofexperiencing the group as a safe and nonshaming environment. She has witnessed and observed thatover time and finally determined that she would move in more fully. Group cohesion enables her todo—the feeling of belonging, safety, and acceptance promote her self-disclosure. In turn, her trust inthe group furthers the group members’ sense of emotional bond and task effectiveness. The group isdoing what it should be doing. This creates the platform for the illumination and disconfirmation of

EVIDENCE-BASED GROUP PSYCHOTHERAPIST 295

group members’ toxic pathogenic beliefs through relational experience and insight—in Melanie’scase detoxifying the critical shame that had kept her disengaged in the past and fostered affectavoiding self-destructive behaviors.

At the same moment, the group is functioning as a social microcosm as members bring themselvesgenuinely into the here and now. Noah’s behavior is, in fact, exactly what he needs to be demonstrat-ing, as it creates an opportunity for illumination and for the disruption of negative relationalcomplementarity and maladaptive transaction cycles. It feels much more congruent with one’s senseof self as a therapist to engage Melanie in ways that disconfirm her pathogenic beliefs—but equallyimportant to do so with Noah even though, or particularly because, it generates an uncomfortablecountertransference. Key to addressing countertransference was recognizing the relational comple-mentarity to Noah marked by an initial wish to be nonresponsive to him. Unchecked, not only is atherapeutic opportunity lost but the therapist’s disengagement due to countertransference could serveto amplify neglect and stoke Noah’s self-absorbed interpersonal style.

Alternately, the therapist’s capacity to self-reflect and then engage in therapeutic metacom-munication and feedback creates a therapeutic opportunity. It is essential to tailor the feedback tomaximize alignment with regard to intent and impact to interrupt the interpersonal complemen-tarity of offering perfunctory attention or frank neglect. This has added benefits to the group.The group leader has an essential role in setting group norms and modeling authentic, compas-sionate feedback. In this instance, judicious therapist self-disclosure in commenting about some-thing that was alive and palpable in the group that others, at that moment, felt unable to addressconstructively promotes greater safety and expands others’ capacity to disclose the difficult todisclose. This vignette also underscores the importance of the therapist’s ability to recognize andmetabolize countertransference as a first step before speaking to it. I needed to recognize that Iwas hooked interpersonally and needed to unhook, or I would stay disinterested or angry withNoah, which would have perpetuated another maladaptive transaction cycle for Noah and couldhave encouraged silencing within the group of difficult-to-provide feedback. Instead, I tried touse my disinterest to understand, empathically, Noah’s experience of neglect, weaving that intofeedback that would access more of the recognition and connection that he desperately seeks(Yalom and Leszcz, 2005).

The relatively brief exchange and inquiry from Susan creates an added opportunity to do a focalpiece of work on her plan for therapy. Few questions or statements in the group are disconnectedfrom the client’s core pathogenic beliefs. Although this may be stretching a point to make the point,group leaders are well served by working with the conviction that most interactional sequences in thegroup will serve to be part of the client’s solution or part of the client’s problem. In this instance, inresponding to Susan’s query, I am also guided by my appreciation of her pathogenic beliefs regardinghow much am I present in a reliable and genuine way and how much am I guided only by atechnical, mechanistic model. A final comment about this illustration is the value of processreflection. Moving back and forth from interaction at the level of content to the processing of theexperience of that interaction at every step along the way is essential to illuminate pathogenic beliefsand interpersonal choices that reinforce or disconfirm these beliefs. This opens up many doorswithin the here and now of the life of the group.

Conclusion

The evidence-based practice of group therapy builds upon the common principles and models thatcontemporary group therapists recognize, appreciate, and aim to utilize—notably building andmaintaining cohesive therapy groups and working in a self-reflective and empathic fashion. Nogroup therapist would dismiss these as unimportant and it is expected by our field, our patients, andour colleagues that we aspire to practice in this fashion. This article has aimed at operationalizingthese core ingredients of effective group practice. In this spirit, the empirical literature can becomfortably engaged and utilized.

296 M. LESZCZ

Notes on contributor

Molyn Leszcz, MD, FRCPC, CGP, DFAGPA, is Professor and Vice Chair, Clinical, Department of Psychiatry,University of Toronto and the Psychiatrist-in-Chief at Sinai Health System. Toronto, Ontario, Canada.

References

Baldwin, S. A., & Z. E. Imel. (2013), Therapist effects: Findings and methods. In: Bergin and Garfield’s Handbook ofPsychotherapy and Behavior Change, ed. M. J. Lambert. New York: Wiley, pp. 258–297.

Bennett, D., G. Parry, & A. Ryle. (2006), Resolving threats to the therapeutic alliance in cognitive analytic therapy ofborderline personality disorder: A task analysis. Psychol. Psychother., 79: 395–418.

Bernard, H., G. Burlingame, P. Flores, L. Greene, A. Joyce, J. C. Kobos, M. Leszcz, R. R. MacNair-Semands, W. E.Piper, A. M. McEneaney, D. Feirman, & AGPA Science to Service Task Force. (2008), Clinical practice guidelinesfor group psychotherapy. Internat. J. Grp. Psychother., 58: 455–542.

Burlingame, G., B. Strauss, & A. Joyce. (2013), Change mechanisms and effectiveness of small group treatments. In:Begin and Garfield’s Handbook of Psychotherapy and Behavior Change, ed. M. J. Lambert. New York: Wiley andSons, pp. 640–689.

Burlingame, G. M., D. T. McClendon, & J. Alonso. (2011), Cohesion in group therapy. Psychother. (Chic), 48: 34–42.Chow, D. L., S. D. Miller, J. A. Seidel, R. T. Kane, J. A. Thornton, & W. P. Andrews. (2015), The role of deliberate

practice in the development of highly effective psychotherapists. Psychother. (Chic), 52: 337–345.Colli, A., & M. Ferri. (2015), Patient personality and therapist countertransference. Curr. Opin. Psychiatry, 28: 46–56.Gelso, C. J. (2007), Editorial introduction. Psychother. (Chic), 44: 239.Hannan, C., M. J. Lambert, C. Harmon, S. L. Nielsen, D. W. Smart, K. Shimokawa, & S. W. Sutton. (2005), A lab test

and algorithms for identifying clients at risk for treatment failure. J. Clin. Psychol., 61: 155–163.Hayes, J. A., C. J. Gelso, & A. M. Hummel. (2011), Managing countertransference. Psychother. (Chic), 48: 88–97.Hill, C. E., & S. Knox. (2009), Processing the therapeutic relationship. Psychother. Res., 19: 13–29.Hoglend, P. (2014), Exploration of the patient-therapist relationship in psychotherapy. Am. J. Psychiatry, 171: 1056–

1066.Kiesler, D. J. (1996), Contemporary Interpersonal Theory and Research. New York: J. Wiley & Sons._____. (2001), Therapist countertransference: In search of common themes and empirical referents. J. Clin. Psychol.,

57: 1053–1063.Kraus, D. R., L. Castonguay, J. F. Boswell, S. S. Nordberg, & J. A. Hayes. (2011), Therapist effectiveness: Implications

for accountability and patient care. Psychother. Res., 21: 267–276.Krogel, J., G. Burlingame, C. Chapman, T. Renshaw, R. Gleave, M. Beecher, & R. Macnair-Semands. (2013), The group

questionnaire: A clinical and empirically derived measure of group relationship. Psychother. Res., 23: 344–354.Lambert, M. J., N. Hansen., & S. C. Harmon. (2010), Outcome questionnaire system (The OQ system): Development

and practical applications in healthcare settings. In: Developing and Delivering Practice-based Evidence: A Guide forthe Psychological Therapies, ed. M. Barkham, G. Hardy, & J. Mellor-Clark. Chichester, UK: Wiley-Blackwell, pp.141–154.

Laska, K. M., A. S. Gurman, & B. E. Wampold. (2014), Expanding the lens of evidence-based practice in psychother-apy: A common factors perspective. Psychother. (Chic), 51: 467–481.

Leszcz, M. (2009), Group therapy. In: Comprehensive Textbook of Psychiatry, ed. H. Kaplan & V. A. Sadock.Philadelphia, PA: Lippencott Williams & Wilkins, pp. 413–414.

_____. (2014), The effective group psychotherapist. Groepen, 9: 9–20._____, & J. C. Kobos. (2008), Evidence-based group psychotherapy: Using AGPA’s practice guidelines to enhance

clinical effectiveness. J. Clin. Psychol., 64: 1238–1260._____, & J. Malat. (2012), The interpersonal model of group psychotherapy. In: The Wiley-Blackwell Handbook of

Group Psychotherapy, ed. J. I. Kleinberg. Chichester, UK: John Wiley and Sons, Ltd., pp. 33–58.Luborsky, L., & P., Crits-Christoph. (1998), Understanding Transference: The Core Conflictual Relationship Theme

Method. Washington, DC: American Psychological Association.Mallinckrodt, B., & J. Jeong. (2015), Meta-analysis of client attachment to therapist: Associations with working alliance

and client pretherapy attachment. Psychother. (Chic), 52: 134–139.McCullough, J. P. (2006), Treating Chronic Depression with Disciplined Personal Involvement: CBASP. USA: Springer.Mitchell, S. A. (1993), Hope and Dread in Psychoanalysis. New York: Basic Books.Norcross, J. C., & B. E. Wampold. (2011), Evidence-based therapy relationships: Research conclusions and clinical

practices. Psychother. (Chic), 48: 98–102.Okiishi, J. C., M. J. Lambert, D. Eggett, L Nielsen, D. D. Dayton, & D. A. Vermeersch. (2006), An analysis of therapist

treatment effects: Toward providing feedback to individual therapists on their clients’ psychotherapy outcome. J.Clin. Psychol., 62: 1157–1172.

EVIDENCE-BASED GROUP PSYCHOTHERAPIST 297

Sammet, I., F. Leichsenring, H. Schauenburg, & S. Andreas. (2007), Self-ratings of pathogenic beliefs: A study based onthe psychodynamic control-mastery theory. Psychother. Res., 17: 494–503.

Slone, N. C., R. J. Reese, S. Mathews-Duvall, & J. Kodet. (2015), Evaluating the efficacy of client feedback in grouppsychotheapy. Grp. Dyn.: Theory, Res. and Prac., 19: 122–136.

Strupp, H. H., & J. L. Binder. (1984), Psychotherapy in a New Key. New York: Basic Books.Tracey, T. J., B. E. Wampold, J. W. Lichtenberg, & R. K. Goodyear. (2014), Expertise in psychotherapy: An elusive

goal? Am. Psychol., 69: 218–229.Tritt, A., J. Kelly, & G. Waller. (2015), Patients’ experiences of clinicians’ crying during psychotherapy for eating

disorders. Psychother. (Chic), 52: 373–380.Wachtel, P. (2011), Therapeutic Communication. New York: Guilford.Wampold, B. E. (2001), The Great Psychotherapy Debate: Models, Methods and Findings. Hillsdale, NJ: Erlbaum.Weiss, J. (1993), How Psychotherapy Works: Process and Technique. New York: Guilford.Weissman, M. M. (2013), Psychotherapy: A paradox. Am. J. Psychiatry, 170: 712–715.Yalom, I. D., & M. Leszcz. (2005), The Theory and Practice of Group Psychotherapy. New York: Basic Books.

298 M. LESZCZ