Sweat Therapy Treatment Manual
Carrie Winterowd, Stephen Colmant, and Allen Eason
Oklahoma State University
Significant portions of this manual have been modified from an original manual developed by Robert Morgan, Ph.D., with his permission for Sweat therapy.
SWEAT THERAPY TREATMENT MANUAL
This treatment manual is intended to provide you with a guide for conducting a interpersonal (process-oriented) approach to group psychotherapy with sweat (i.e., in a sauna condition) for college students. This manual is intended to function as a guide to this particular group treatment approach with sweat.
The group treatment approach presented in this manual is based on the interpersonal, process-oriented approach to group psychotherapy as presented by Irvin Yalom (1995) in his classic text on group psychotherapy.
This treatment manual is presented in a fashion that is analogous to the treatment approach. As the interpersonal process-oriented approach is the basis for this treatment, it will be described in detail in Part I of this manual. The sweat treatment strategies will be described in Part II of this treatment manual. This manual was written in a clear and reader friendly format, thus scientific references will be implemented only as specifically warranted. Please note that the interpersonal process-oriented approach as described in this manual refers to the approach described by Yalom. We will not cite him for each statement or explanation, but you should be aware that this is his intellectual work (unless otherwise cited), not ours.
PART I
Interpersonal Process-Oriented Approach
As stated previously, this classic approach to group psychotherapy was initially developed by Yalom in 1970. Yalom’s theory will be described briefly, yet in sufficient detail to allow you to implement this approach. The interpersonal process-oriented approach to group work as described here refers to an exploration of group members’ interpersonal relationships with each other as well as their relationship to you (the facilitator). This exploration occurs within the group and remains the focus of the group, therefore the process of this approach is centered in the “here and now” (i.e., the present) and focuses on interpersonal relationships.
In describing this treatment approach, Yalom (1995) has indicated several key components which you must be aware of and attempt to implement to adequately facilitate this interpersonal process-oriented approach to group therapy. These components include: the eleven therapeutic factors of group work, culture building and norm shaping, and maintenance of a “here-and-now” focus. In addition, stages of group therapy and group dynamics will be discussed briefly. These components are described briefly here, and will be presented in greater detail in the first two of the four training sessions.
The students who participate in this study will be referred through this manual as “clients” or “group members.” The facilitators of the groups will be referred through this manual as “facilitators.” The interpersonal process-oriented groups with or without sweat will be referred throughout this manual as “groups” or “group therapy.”
Therapeutic Factors:
Yalom (1995) has empirically identified eleven therapeutic factors based on the “intricate interplay of human experience” (pg. 1) and that opens the path way to therapeutic change. These eleven factors are: (1) Instillation of Hope, (2) Universality, (3) Imparting Information, (4) Altruism, (5) The Corrective Recapitulation of the Primary Family Group, (6) Development of Socializing Techniques, (7) Imitative Behavior, (8) Interpersonal Learning, (9) Group Cohesiveness, (10) Catharsis, and (11) Existential Factors. The following is a description and therapeutic explanation of each of the eleven therapeutic factors.
Instillation of Hope: Hope is crucial to the therapy process. Group members (and facilitators) need to achieve and maintain hope that change is possible. Hope is required to not only keep clients in therapy, but “faith in a treatment mode can in itself be therapeutically effective” (pg. 4). As the group facilitator, you must be able to communicate how this group approach will help group members. In addition, you should attempt to capitalize on their hope in the efficacy of this treatment approach whenever possible (e.g., early group sessions, reinforce positive expectations, educate when faced with negative preconceptions, and direct attention to improvements displayed during the course of the group).
Universality: Clients may enter group therapy with the preconceived idea that they are alone with their problems and that others do not share similar difficulties. While this is true to some extent, the disconfirmation of their uniqueness may be a powerful sense of relief. That is, clients learn that they are universally similar to one another. It is assumed that as clients begin to share and learn about each others’ similarities, they will become more trusting and open with each other. Your role is to aid in the development of group universality by pointing out similarities among group members. When clients present with problems or goals that are similar it is important that you indicate the universal nature of their issues. This may be most easily achieved during the first group session. As clients begin to discuss their lives, you will help the group identify commonalties in their life histories, issues, and goals.
Imparting Information: This therapeutic factor includes both didactic instruction (e.g., psycho-education) and direct advise (by the facilitator as well as group members). In general, clients in interpersonal process-oriented groups do not highly value didactic instruction or advice giving, and Yalom discourages such practices. As the facilitator, you may chose to use psychoeducation or offer suggestions to some group members to facilitate their growth and improvements. However, it is recommended that you not overuse these interventions. Group members will also give advice to one another, especially in early stages of the group. While group members typically do not find the advice of other group members as highly beneficial, advice giving serves a purpose. The process, rather than the content is important as it implies and conveys mutual interest and caring. This is an important facet of group therapy and clients may benefit from acknowledging that they are interested in and care about one another.
Altruism: In group therapy, clients receive through giving. Clients may particularly benefit from this factor as it may be one of the few times that they give rather than take. Clients may believe that they are a burden to others and the experience that they can be helpful or of importance to others may be refreshing and may boost self-esteem. Clients in group therapy may be helpful to one another via providing support, reassurances, suggestions, insight, and sharing of problems. Not infrequently, clients in group therapy will accept observations from other clients long before they accept your observations. You may be perceived as a professional who is not from the real world, who can not really understand them. Other clients are real and understand their plight, thus, are more credible sources of information. Typically, clients question the utility of group therapy asking questions such as “How can the blind lead the blind?” This resistance may be best explored through the therapeutic factor of altruism. In effect, a client who says other clients are in the same position as him/herself and cannot possibly be of help to him/her, is in effect saying “these clients are like myself, and I have nothing of value to offer them.” You can assist these clients in exploring their negative self-evaluation by helping them identify ways that they can be of assistance to the group. Others may vicariously benefit from this process exploration. In addition, it may prove beneficial to reflect the support you notice in group sessions.
The Corrective Recapitulation of the Primary Family Group: Group dynamics occur that closely resemble familial dynamics. Many aspects of families are re-experienced in groups: authority/parental figures, peer siblings, strong emotions, deep intimacy, and hostile and competitive feelings. Responses to other clients in the group will be similar to reactions to family members. Of therapeutic importance, however, is not that early family experiences or conflicts are merely relived, rather that they are relived correctly. Your task is to find common ties between past and current feelings, thoughts, and behaviors, and to explore and challenge rigid interpersonal behaviors. You should assist clients in identifying behaviors that are heavily influenced by early family experiences, and encourage them to experiment with new interpersonal behaviors in the group. The group should be a safe haven for them to try on new behaviors. Thus, when clients can work out problems with you and the other members, they are actually working through unfinished business from previous relationships.
Development of Socializing Techniques: Groups provide an instant laboratory for the observation and development of social skills. The development of socializing skills in an interpersonal process-oriented group is a secondary gain as social skills training is usually not a focus of these groups; however, clients may learn from others’ feedback about their social behaviors. This may provide clients with a unique opportunity of receiving direct feedback regarding their interpersonal skills. It appears intuitively plausible that this feedback could only help clients in their interpersonal relationships within and outside of the group. Yalom (1995) emphasizes the potential benefits of this therapeutic factor when he states “senior members...are attuned to process; they have learned how to be helpfully responsive to others; they have acquired methods of conflict resolution; they are less likely to be judgmental and more capable of experiencing and expressing accurate empathy.” Your task here is to aid clients in developing more functional social skills via modeling (i.e., demonstrating the behavior yourself directly or indirectly) and/or feedback.
Imitative Behavior: We have all at one time or another imitated behaviors of others. Group therapy is no different as clients will model their own behavior based on your behaviors and/or the group members’ behaviors. Clients in this group will likely “try on” bits and pieces of other people in group and then keep those behaviors that “fit” and discard qualities that are ill-fitting. Yalom (1995) articulates this point very succinctly when he writes about this process of trying on and discarding others qualities or characteristics as beneficial because finding out who we are not is important for finding out who we are.
Interpersonal Learning: Interpersonal learning is by far the most abstract and difficult to explain of all of Yalom’s therapeutic factors. Interpersonal learning includes processes that are similar to individual therapy such as insight, working through transference, and the corrective emotional experience. To understand interpersonal learning as identified by Yalom, you must first be familiar with his view of the importance of interpersonal relationships, the corrective emotional experience, and the group as social microcosm.
Interpersonal relationships are important because we develop a sense of who we are based on the perceptions and reflections of others. In general, most clients try to live life based on their own values and standards and in a way that others can be proud of them. With regard to interpersonal relationships, individuals have a tendency to distort perceptions of others (Yalom refers to these distorted perceptions as “parataxic distortions”). These distortions occur in response to facilitators as well as group members. For example, a chronically angry and resentful client may perceive others as harsh and rejecting. If this projection can be identified and discussed in group, than s/he may be in a unique position to obtain consensual validation (i.e., obtain feedback from the group with regard to his/her self-evaluation).
It is assumed that the group will rekindle previous emotional experiences but that the client will be allowed to experience a “corrective emotional experience”. That is, client growth may develop through self-disclosure of emotionally laden material and group feedback allows for reality testing. Five components appear of utmost importance with regard to the “corrective emotional experience”: (1) clients will take risks of expressing strong emotional reactions; (2) the group must support the clients’ risk; (3) group process is examined; (4) inappropriate feelings and behaviors or avoided interpersonal behaviors are recognized; and (5) more honest and deeper interactions are facilitated. Again, it should be noted that the emotional expression is not sufficient to promote change and that a cognitive component (i.e., reflecting on the experience and finding meaning in it) is essential for change to occur. You will need to assist the group by framing and/or making sense of the emotions exhibited in the group.
One of the primary benefits from interactive groups is that they facilitate a social microcosm of the group members. In other words, group members begin to interact with one another as they do with others outside the group. In many ways, the group will represent their day-to-day world. With the passage of time, group members will be themselves during group interactions. As a result, they will eventually display their own problems or pathologies. You do not need to ask about their problems or pathologies, because they will display it for you and for everyone else to see. One of your most significant tasks will be to identify and subject to therapy those maladaptive interpersonal behaviors of individual group members and help them learn new ways of relating. Prior to turning the social microcosm to a therapeutic advantage, you must first identify group members’ recurrent maladaptive patterns. Group members will elicit feelings from one another, and you need to consider these feelings as data. If these are not the feelings that the client desires to elicit, then a problem has been identified. Note that one response of another group member is insufficient data and you must seek confirmatory data (from other group members as well). Consensual validation (feedback about one’s self-evaluation) from the group must be obtained to truly aid in the identification of maladaptive interpersonal styles in each group member. Some of the complaints frequently voiced by clients is that the group and it’s interactions are not representative of the real world—that the group is artificial and contrived. It should be pointed out that while the group members meet only once a week, they are in a position to explore with great depth the life experiences and interpersonal functioning’s of one another. To develop the kind of trust and honest necessary to work together cannot possibly be considered artificial. There is nothing artificial about a client expressing anger with you or another client. In fact, in many ways, group experiences can be more real than their everyday life.
Lastly, the therapeutic factor of interpersonal learning must include a discussion of insight. Insight is the discovery of something of importance about oneself, and may occur on at least four different levels.
1. Clients may develop an objective impression of their interpersonal style. They may learn how others view them.
2. Clients may develop an understanding of their interactional patterns.
3. Clients may develop an understanding of the motivations behind their interactional patterns. They may learn why they interact the way they do. For example, clients may learn that they behave in certain ways to avoid perceived catastrophes (e.g., if I express my anger I will end up in a fight; if I cry I will be perceived by others as weak).
4. Clients may develop an understanding of how they became the way they are.
Group Cohesiveness: Group cohesiveness in its most basic form refers to the attractiveness of a group for its members. Defined more behaviorally, group cohesiveness refers to members feelings of warmth and comfort in the group, feelings of belonging, valuing the group, and feelings of being valued, unconditionally accepted and supported by the other group members. Group cohesiveness appears to be a necessary component of group therapy, as well as any other group, should be able to develop this therapeutic factor. Group cohesiveness is not a stagnant process, rather, the cohesiveness of any group fluctuates with the circumstances of the group; however, some level of group cohesiveness must be maintained or members are likely to leave the group.
Lastly, it is critical to the process of group therapy that you do not misinterpret group cohesiveness as comfort. Cohesive groups should be better able to develop and express anger and conflict. Hostility must be acknowledged and expressed to avoid covert hostility, which would significantly hinder the effectiveness of the group. Hostility in group therapy must be processed and it is imperative that the conflicting group members establish a means of working together. Clients may have a tendency to avoid open expression of anger and hostility, however, as the group facilitator you need to help the group identify and explore conflict via the open expression of anger. Be aware and prepare for the initial expression of anger to be directed at you. If the group members cannot trust you with their anger, how can they trust the other clients. This issue will be discussed in greater detail under the heading of “stages of group therapy”, but suffice it to say for now, that you should observe client challenges or confrontations at some point in the early group development. For example, you may be confronted about your lack of direction or your lack of care and concern. If you do not deal with this open expression of anger in a healthy and positive way (e.g., allow members to share their disappointment, anger, etc. without judgement), you will inadvertently establish a group norm discouraging the open expression of intense feelings.
Catharsis: Catharsis is the process of emotional experience and generally refers to expressing and discharging previously repressed emotions. It is generally accepted by most theorists and clinicians that catharsis is not sufficient to promote psychological change. As the facilitator, one of your tasks is to help the client get beyond the ventilation of feelings and attempt to add meaning or significance to the cathartic experience. You must facilitate the dual process of expressing feelings and then reflecting back on the process (this process is known as the self-reflective loop and is discussed in greater detail below). For example, you might ask a group member what it was like to share those feelings in the group just now. Catharsis is critical to group therapy, without which the group would be a sterile intellectual discussion of ideas and thoughts, yet it is insufficient to promote change and must be supplemented by other therapeutic factors. In addition, this therapeutic factor allows clients (possibly for the first time in their lives) to learn and be able to say what is bothering them. With regard to catharsis with clients, please note that expression of affect is a relative experience. What one perceives as intense may not be the same as what others perceive as intense. Thus, if a relatively constricted client expresses an affective response, consider the experience from that client’s experiential world.
Existential Factors: The existential factors refers to the search for purpose and meaning in life, and consists of five points:
(1) “Recognizing that life is at times unfair and unjust”
(2) “Recognizing that ultimately there is no escape from some of life’s pain or from death”
(3) “Recognizing that no mater how close I get to other people, I must still face life alone”
(4) “Facing the basic issues of my life and death, and thus living my life more honestly and being less caught up in trivialities”
(5) “Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others” (p. 88).
In a general sense these five existential factors emphasize awareness of death, freedom, isolation, the purpose of life and the struggle with existence. This therapeutic factor is not grounded in techniques or strategies, instead, it is an attitude or a way of viewing the world. Your task is to aid the client in exploring his/her role in the world and way of living.
Integrating the Therapeutic Factors
As you read about the eleven therapeutic factors you probably developed a sense of those therapeutic factors that carry more weight with regard to the change process. Yalom would not disagree with you. For example, instillation of hope in and of itself does not facilitate change, however, it helps keep members in the group to allow other therapeutic factors to facilitate change. In addition, the therapeutic factors should not be considered individually, but collectively. Each factor contributes and is critical to the process of change. If you think of the change process in a circular fashion with change at the top of the loop and each factor leading in a circular fashion to change, you can see that if any one factor is removed, the loop is broken. Thus, each factor is not necessarily a condition of change, rather a mechanism in the process of change. One of your goals for your group should be to facilitate the process of change by integrating the therapeutic factors as described above.
Culture Building and Norm Shaping:
One of your tasks as the group facilitator is to develop a group that works as a “therapeutic social system” (pg. 109). That is, you are not the agent of change, the group is. It should be the group members who facilitate change for one another via the therapeutic factors, thus it is your task to establish a group culture that maximizes the effective therapeutic interactions. Your task is to maximize the strengths of the group to facilitate an interactional group.
In building a therapeutic culture, group norms will evolve. Some of the norms of the group will be explicit (e.g., identified group rules as described below), while most will be implicit. You influence the type of norms that evolve. In fact, you cannot help but influence the development of group norms. You need to be conscious of your influence on group norms and attempt to establish norms that facilitate interactional group therapy. In developing group norms you will assume two basic roles: technical expert and model-setting participant.
As the technical expert, you do not need to rely on group exercises or gimmicks to develop therapeutic norms. Rather, you can rely on your knowledge and experience to actively facilitate the group norms. You already possess the necessary techniques for the development of the desired norms. You simply need to be conscious of how you effect group norms and plan your strategy appropriately. Yalom (1995) gives the following examples which I believe adequately describe your task here:
“the leader must attempt to create an interactional network in which the members freely interact rather than directing all their comments to or through the facilitator. To this end, facilitators may implicitly instruct members in their pregroup interviews or in the first group sessions: they may, repeatedly during the meetings, ask for all members’ reactions to another member or toward a group issue; they may wonder why conversation is invariably directed toward the facilitator; they may refuse to answer questions or may even close their eyes when addressed; they may ask the group to engage in exercises that teach clients to interact-for example, asking each member of the group, in turn, to give his or her impressions of every other member; or facilitators may , in a much less obtrusive manner, shape behavior by rewarding members who address one another-facilitators may nod or smile at them, address them warmly, or shift their posture into a more receptive position” (pg. 113).
As the model-setting participant, you shape group norms by example. You should attempt to model four basic functions: (1) honest and open communication, (2) appropriate restraint, (3) appropriate self-disclose (i.e., as the facilitator, do not self-disclose too early in the group and avoid promiscuous self-disclosure), and (4) transparency (i.e., do not hide behind your role as group facilitator). To function as a model you must “join” the group. You will be expected to share with the group. You will not need to share identifying information (a process that can prove dangerous with this population), however, you should be willing to share your own interpersonal difficulties with the group. For example, if you find yourself in constant conflict with a particular client you can model trust and openness by exposing this conflict to the process of the group. You will model honest and open communication and transparency, but to do this you must be comfortable with yourself and allow yourself to come out from behind your role as facilitator. In effect, you become a group member who is subjected to interpersonal difficulties just like every one else in the world. Finally, you should positively reinforce similar client behavior. Do not punish those who are less trusting and share only minimally. You should reinforce them for what they have shared, you can process their difficulty in opening up more to the group, you can engage in risk assessment of opening up, and you can encourage clients to share more, but do not act in a punitive manner to the amount or your perceived tardiness of their sharing. To do so, will inadvertently reinforce negative feelings of sharing. Clients will learn that sharing only leads to greater expectations of what one must share, and everyone will be afraid to be more open with the group.
Here-And-Now Focus
As stated previously, the here-and-now refers to the focus on the interpersonal relationships within the group and occurs in the present. The focus on the here-and-now is of paramount importance in Yalom’s theory and is a concept that you will need to be familiar and comfortable with to facilitate an interpersonal process-oriented group. For this reason, I contribute more detail to this concept than any other concepts in this theory. To implement a here-and-now focus you need to know that this process occurs at two levels: first is an experiential level and second is an “illumination of process” level.
In the experiential level, group members will experience feelings in the here-and-now. Some of these feelings will be strong and will be in reaction to other group members, the facilitator, and the group at large. The focus of this portion of the group will be on these feelings. Identifying and sharing with the group these feelings will be one of your primary goals for each of the individual members. The events in meetings must take precedence over any other events (e.g., outside the group). That is not to say that other events in the clients life are not to be discussed, however, the group focus must remain on intergroup behaviors. The here-and-now focus will remain incomplete without the second level, the illumination of process. That is, you must facilitate “process commentary” (i.e., explaining what you observed/heard happening in the group) on the events that occur in the here-and-now. Experiencing is insufficient to facilitate change; experiencing must by accompanied by interpersonal learning which occurs through process commentary (e.g., reflection on the experience and sharing it in group). Thus, you have two tasks: 1) facilitate a here-and-now focus and then 2) lead the group in an exploration of the here-and-now experiences (e.g., thoughts, feelings, behaviors, interactions). In effect, the group will perform a “self-reflective loop”. The group will live in the here-and-now, and then reflect back on the thoughts, feelings, behaviors, and/or interactions that occurred.
For purposes of this group, process will refer to the interpersonal relationships between group members. Process is not the same as content. Content refers to the explicit meaning of statements, whereas process refers to underlying meanings. To understand the process you need to consider the reason, from an interpersonal perspective, that clients make statements when they do, how they do, and to whom they do. In other words, why is a client saying what s/he is saying, how s/he is saying it, and to whom s/he is saying it. This is the group process and it is this process commentary that separates experiential group therapy from other social interactions.
Some techniques may aid you in activating a here-and-now focus; however, you are strongly encouraged not to rely on these techniques in a prescriptive format, rather to understand the purpose and intent behind the techniques. In so doing, you will then be in a position to initiate your own techniques that are consistent with your own individual style. First, it may help you to think in the here-and-now. Your focus should be on attempting to bring each group session, each event into the here-and-now. Ask yourself a question such as, “How can I get this discussion into the here-and-now?” This will help keep you in a here-and-now focus. This should be done as early as the first group session. For instance, after group introductions and initial discussion, you may interrupt the group with a process comment. Yalom provides the following narrated example “We’ve done a great deal here today so far. Each of you has shared...But I have a hunch that something else is going on, and that is that you’re sizing one another up, each arriving at some impressions of the other, each wondering how you’ll fit in with the others. I wonder now if we could spend some time discussing what each of us has come up with thus far.” As you can see from this example, you can directly influence a here-and-now focus. You will attempt to adjust the focus from the external, abstract, and impersonal, to the internal, specific, and personal. Encourage the use of first person (“I”) rather than third person (“You”). Identify when group members are talking to you and encourage group communication. Other examples of moving the focus to a here-and-now focus will be presented in the training sessions.
Another strategy is to provide feedback on how to ask and give feedback to and from other group members. It may be necessary for clients to occasionally check out their beliefs with the group. Help clients avoid group questions such as “Do you like me?” in favor of more effective questions such as “What is it about me that you like most and least?” This type of activity promotes process commentary and includes the following sequence:
1. A description of behavior. Clients learn to see themselves as others see them.
2. Here is the impact of your behavior on others. Clients learn how their behavior makes others feel.
3. Here is the impact of your behavior on others attitudes toward you. Clients learn how others feel about them as a result of their behavior.
4. Here is the impact of your behavior on your attitude toward yourself. Clients learn how their behavior influences their own attitude about themselves.
When initially inquiring about intergroup relations, you will receive resistance from the group. Clients will say something to the effect that they like all of the group members the same. It may be important for you to accept these defenses initially, but stay with the task, continue to probe and explore, and do not hesitate to model interpersonal communications. For example, after a long silence you may initiate “process commentary” by asking for the thoughts of the group members that were “unsaid”. You can then model this behavior by sharing your own thoughts that occurred during the silence.
At times it may occur to you that things are going “unsaid” as the group is nearing the end. You may have the members imagine that the group has just ended and they are leaving. Ask them what disappointments they would have about that session. Also, do not hesitate to wonder about how group discussions relate to the group session (e.g., if they are discussing the frustration of clients in the facility, wonder aloud if that is how they are feeling in the group). Your wondering may or may not be accurate, but either way, you facilitate a here-and-now focus.
Once you have established a here-and-now focus, you must then use this process therapeutically (i.e., process illumination). The illumination of process consists of four stages: (1) client recognition of their behavior, (2) client understanding of the effects of this behavior, (3) determine their satisfaction with their behavior, and (4) change in behavior. To facilitate these stages you must first be able to recognize process. This is a skill that generally occurs with experience, and you may or may not have had opportunities to develop this skill. Some specific examples will be provided to aid you, as needed, in the recognition of process.
Establishing a process orientation within the group is as difficult and maybe moreso than establishing a here-and-now focus; however, another one of your tasks will be to facilitate an environment that accepts a process orientation. In so doing you are encouraged to attempt to facilitate client learning via their own route. That is you may have to hold onto some process commentary until you are able to find a method that allows the client to obtain their own insight. This will carry much more weight than any brilliant interpretation that you as a facilitator can offer. This is not an easy task, and as the time frame for this group is relatively short (especially by Yalom’s standards) you are encouraged to weigh the time limits against the clinical utility of making an interpretation.
When you chose to illuminate on the group process, you are advised to consider how you can aid the client in hearing your process commentary. Some basic concepts are suggested here. First and most obvious, clients may hear your interpretations more clearly if they are framed in a supportive manner. Second, avoid the temptation to label or classify (e.g., antisocial, narcissistic, uncaring). A statement first describing some positive aspect of their group behavior followed by an observation and interpretation of the ineffective or aversive group behavior may be more easily heard by the client. Third, be observant of “moments of truth”. That is, their are times when in an instant of openness an client discloses some truth that will provide you with therapeutic leverage at a later point in the group. For example, a client may state that they would like to develop more intimate relationships with others. By remembering this statement you may be in a position to use his/her stated desire in making a process commentary to how his/her intergroup behavior effects relationships with others in the group.
If any of this information is unclear, I will reiterate many of these points during the first two training sessions. In addition, videotapes produced by Yalom will accurately display the use and impact of the here-and-now focus.
Stages of Group Psychotherapy
Yalom (1995) identifies three stages of group therapy that all groups must obtain in order to become a functional therapeutic group. These stages include the initial stage, the conflict, dominance and rebellion stage, and thirdly, the development of cohesiveness. These stages are not clearly defined as to when or how a particular group will progress through each stage, but as the facilitator you should be able to recognize and process with the group, the stages as they occur.
The initial stage (also referred to by Yalom as the “in or out” stage) is characterized by four basic phases. First, there must be an orientation to the group. You can facilitate this phase by discussing the purpose of the group, expectations of group members, and structure of the group. Second, it is normal for group members to be hesitant about group participation and self-disclosure. Trust has not yet formed and the clients will continue to seek approval from the group rather than openly discuss their life struggles. Thirdly, the group will experience a “search for meaning” phase. The clients will attempt to make sense of the group, ask and explore how the group will help them, they will question how much they really want to share, and they will attempt to find a role within the group. Finally, there will be a dependency phase. Here the clients will look for structure, typically from you. They will seek you out for direction, approval, acceptance, and you will see many of the group statements directed to you. You can exert great influence at this point and must remember that you are attempting to establish therapeutic norms as described previously.
The second stage of group therapy is the conflict, dominance and rebellion stage (which Yalom also refers to as the “top-bottom” stage). Here the group shifts focus from approval and acceptance to conflict, dominance, and power. A group hierarchy will likely emerge as clients jostle for position within the group. In this stage, the clients are becoming more real and you will begin to see who the group members really are. Controlling and dominant clients will attempt to assume control in the group, while more passive clients will allow the group to be directed by others. The clients are allowed to be a little more real because in this stage they are becoming more comfortable with one another. The first sign that the second stage is occurring is the emergence of conflict. This conflict will typically not present itself in a hostile or aggressive fashion. Rather, subtle disagreements will become evident. This is the group’s method of “testing the waters” for the acceptance of conflict. As stated previously, group conflict will invariably be directed to you first. If they can not express conflict with you the facilitator, how can they trust to express conflict with one another, and a group without conflict will be like a marriage without conflict--boring, distant, detached, and unreal. You must be prepared to accept conflict, no matter how great or small the challenge, because the group’s challenge of you is essential to the life of the group. As such, you must not only permit but encourage confrontation (e.g., reinforce challenges) directed at you. Rest assured, the group will save you and eventually switch the focus of the challenges from you to one another.
Group cohesiveness is the third and final stage of group therapy identified by Yalom. He has also referred to this stage as a “close-far” stage. This stage is characterized by an increase in trust, self-disclosure, and group cohesion. The focus typically shifts from a conflictual process to one of intimacy. This stage permits the emergence of the real person and secrets are commonly shared. The group develops the cohesion necessary for intimate work to occur. Group cohesion is a relative term. Clients may develop a strong sense of cohesion that is not easily recognized by facilitators experienced with groups that have achieved more intimate levels. You should caution against harboring high expectations, yet allow yourself to develop a sense for and some expectations for intimacy to occur within the group. You should acknowledge with the group their movement towards intimacy and closeness and reinforce behaviors that initiate this process.
Some Notes about Group Dynamics
You already have a good sense about group dynamics, both from experience and from reading the previous sections of this manual. In this section, I want to clarify or describe some of the important group dynamics identified by Yalom (1995) that you should be aware of but that were not identified above. These dynamics include: group maintenance, group resistance, and problem clients.
Group maintenance will be one of your primary tasks once the group has begun. You must identify and deter any threats to group cohesiveness. Frequent tardiness, subgrouping, and scapegoating are examples of processes that can negatively impact group cohesiveness. You need to monitor the cohesiveness of the group and it may be necessary at times to delay work on an individual’s problems for the betterment of the group. For example, if a new client enters the group and is unacknowledged while another group member immediately engages in a dialogue of his problems, you should consider stopping this member and processing with the group the new members presence and the groups lack of acknowledgment to him. Again, you should attempt to confront this behavior in a nonpunitive manner. For example, you may ask the speaking client how s/he thinks the new client is feeling in the group at that point.
Group resistance is common in any group therapy. You may frequently observe group members becoming resistant (generally defined as pain avoidance) to you, to other group members, or to the group at large. When this occurs, your task is to help the client see through their resistance to be able to hear the message they are receiving. It is only then that they can accurately confirm or disconfirm a message. For example, it is likely at some point in your group that a group member will make an observation or interpretation to another group member who in turn becomes defensive and resistant to this message. You may encourage the client to listen to the message by acknowledging his/her ability to defend against or counter the message, but point out that in so doing, s/he is unable to accurately hear the message and is unable to discern which parts of the message are actually true for him/her.
Problem clients exist in all groups, and your client group will be no different. Common problem patient presentations include: the monopolist (talks a great deal in group), the silent patient (talks rarely), the boring patient (detailed stories that stay at a surface level), and most common for your group, the characterologically difficult client (personality problems/disorders). These group members will test your clients as well as your abilities to facilitate a therapeutic group; however, you may be helped in knowing that these are examples of interpersonal problems. You may at times be unsuccessful in your attempts to confront or challenge this behavior, but you may find success in providing your insights (or interpretations) on how the behavior affects their interpersonal relationships. Furthermore, you will be especially effective if you can aid the client in identifying how the effects of his behavior actually contradict what he desires in interpersonal relationships.
Summary of an Interpersonal Process-Oriented Approach to Group Therapy
This approach to group psychotherapy with clients will incorporate Yalom’s (1995) interpersonal process-oriented theory. The foundation of this treatment will consist of eleven therapeutic factors: instillation of hope, universality, imparting information, altruism, the corrective recapitulation of the primary family group, development of socializing techniques, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors. These factors do not facilitate change independently, rather should be implemented collectively into the treatment process. One of your tasks is to facilitate a culture and develop norms that are conducive to interpersonal exploration. This interpersonal exploration should occur in the here-and-now, as group members will react with emotion to the group members, the facilitator, and the group as a whole; however, this is not sufficient for change. You must facilitate a self-reflective loop where group members share their feelings and then reflect back on this experience with the group. Lastly, you should be aware of the group stages your group members may progress through including: the initial stage (characterized by group orientation, hesitant participation, a “search for meaning”, and dependency); the conflict, dominance and rebellion stage (characterized by a focus shift to issues of conflict, dominance, and power); and the group cohesiveness stage (characterized by increased trust, self-disclosure, and group cohesion).
By now you should have a sense of your task when facilitating an interpersonal process-oriented approach to group counseling. It is hoped that Part I of this manual has prepared you for facilitating a therapeutic environment that is rich in opportunity for interpersonal understanding and growth. The avenue to this end lies in the therapeutic factors and the here-and-now process as described previously. As you move into Part II of this manual you are advised to maintain your present awareness of the interpersonal process-oriented approach.
PART II
Sweat Approach
Preparation
Each participant and facilitator will need the following:
1 Quart of water.
Two Towels
Minimum attire is a bathing suit.
The facilitator should have a digital watch with a timer and alarm as is on an athletic watch. A Timex Ironman watch is excellent.
Structure of Sweating Sessions
After members are seated and the door is closed, the facilitator will start his/her watch timer. The group will begin spending four, ten-minute intervals in the sauna. In this manual, the intervals spent in the sauna will be referred to as “Rounds”. After each round, the facilitator will direct the participants to leave the sauna to take a five-minute break in the room directly across from the sauna. The facilitator should encourage everyone to drink plenty of water. Remaining standing between rounds may be helpful for anyone experiencing light-headedness. When the five-minute break is up, the facilitator will direct the participants to re-enter the sauna for the next round. Each subsequent session, along with the group’s consent, the facilitator will raise the amount of time during the rounds by one minute, not to exceed 15 minutes. For example, Session 1 will be four ten-minute rounds, Session 2 will be four eleven-minute rounds, and so forth. It is important that all group members be encouraged to take breaks from the sauna whenever they feel it necessary. Other information regarding signs and symptoms of people having problems due to heat exposure are in the following section on Heat Disorders.
One of your roles as a group facilitator is to ensure the physical and emotional safety. If the facilitator is concerned about the emotional (e.g., undue group pressure or ridicule; being verbally abused) or physical (e.g., people touching each other inappropriately; not respecting physical space and boundaries) well-being of group members as a result of group dynamics or group conflicts, then the facilitator should intervene to interrupt these group dynamics and discuss them. Below is a list of other physical safety concerns that the group facilitator must attend to:
I. HEAT DISORDERS
If a group member is suspected of suffering either a heat related or other injury the counselor will attend to that person and will instruct another group member to inform health club staff of the problem.
A. HEAT STROKE occurs when the body's system of temperature regulation fails and body temperature rises to critical levels. This condition is caused by a combination of highly variable factors, and its occurrence is difficult to predict. Heat stroke is a medical emergency. The primary signs and symptoms of heat stroke are confusion; irrational behavior; loss of consciousness; convulsions; a lack of sweating (usually); hot, dry skin; and an abnormally high body temperature, e.g., a rectal temperature of 41°C (105.8°F). If body temperature is too high, it causes death. The elevated metabolic temperatures which contribute to heat stroke, are also highly variable and difficult to predict.
If a group member shows signs of possible heat stroke, professional medical treatment should be obtained immediately. The person should be escorted out of the sauna. The person’s skin should be wetted and air movement around the person should be increased to improve evaporative cooling until professional methods of cooling are initiated and the seriousness of the condition can be assessed. Fluids should be replaced as soon as possible. The medical outcome of an episode of heat stroke depends on the victim's physical fitness and the timing and effectiveness of first aid treatment.
No person suspected of being ill from heat stroke should be sent home or left unattended unless a physician has specifically approved such an order.
B. HEAT EXHAUSTION. The signs and symptoms of heat exhaustion are headache, nausea, vertigo, weakness, thirst, and giddiness. Fortunately, this condition responds readily to prompt treatment. Heat exhaustion should not be dismissed lightly, however, for several reasons. One is that the fainting associated with heat exhaustion can be dangerous so the victim should not be left unattended; moreover, the victim may be injured when he or she faints. Also, the signs and symptoms seen in heat exhaustion are similar to those of heat stroke, a medical emergency.
People suffering from heat exhaustion should be removed from the hot environment and given fluid replacement. They should also be encouraged to get adequate rest.
C. HEAT COLLAPSE ("Fainting"). In heat collapse, the brain does not receive enough oxygen because blood pools in the extremities. As a result, the exposed individual may lose consciousness. This reaction is similar to that of heat exhaustion and does not affect the body's heat balance. However, the onset of heat collapse is rapid and unpredictable.
D. HEAT RASHES are the most common problem in hot work environments. Prickly heat is manifested as red papules and usually appears in areas where the clothing is restrictive. As sweating increases, these papules give rise to a prickling sensation. Prickly heat occurs in skin that is persistently wetted by unevaporated sweat, and heat rash papules may become infected if they are not treated. In most cases, heat rashes will disappear when the affected individual returns to a cool environment.
PART III
Group Intervention Plan
Intake Interview:
1. Establish rapport
2. Discuss limits of confidentiality (obtain signature on confidentiality form)
3. Provide an overview of the program
• focus on interpersonal relationships
• describe the purpose and procedure of the assessment phases
• discuss group rules/norms
4. Obtain informed consent and have client sign consent form
5. Obtain background information via your normal
clinical interview style
Session 1:
1. Administer pretest measures.
1. Discuss group rules including confidentiality (including your limits to confidentiality)
2. Facilitate group introductions
3. Begin implementing the therapeutic factors (e.g., universality, instillation of hope)
4. Begin to facilitate a here-now-focus
Sessions 2, 4, and 5:
1. Administer 2 questionnaires (Curative Factor Scale and Group Response Form) at the end of each session before members leave.
Session 3:
1. Affect scales will be administered five (5) times. The scales are the PANAS, SEES, and EIFI. They are stapled together and highlighted for administration times: PRE, DURING, POST, 2HR-POST, and NEXT-DAY-POST. Administer PRE before beginning session.
2. Administer DURING on a clipboard five minutes into the third round.
3. Administer POST and 2 questionnaires (Curative Factor Scale and Group Response Form) at the end of session after exiting sauna before members leave.
4. 2HR-POST and NEXT-DAY-POST will be given to group members to take home and fill out on their own. Instruct members to complete 2 HR-POST two hours after end of session. Instruct members to complete NEXT-DAY-POST at 10 AM the following day.
Session 6:
1. Begin the group.
2. Provide the opportunity for some closure and feedback about the experience in group (e.g., What was this group experience like for you?).
3. Administer 2 questionnaires (Curative Factor Scale and Group Response Form) at the end of session before members leave.
Session 7:
1. Administer post-test measures. Group counseling will not be held. Thank everyone for their participation.
