Preparation of Patients for Group Therapy
A Controlled Study
Irvin D. Yolom, MD; Peter S. Houts, PhD; Gary Newell, AB; and Kenneth H. Rand, AB, Palo Alto, Calif
WILL an explanatory session preparing
prospective patients increase the efficacy of
group therapy? This article describes a con-
trolled research project designed to answer
this question.
The query springs from many sources.
Laboratory and clinical group research has
demonstrated the crucial importance of ear-
ly meetings in shaping the future course of a
group.1 Group norms established early in
the life of the group tend to persist, outliv-
ing even a complete turnover in the group
population.2 Approximately one third of all
patients beginning group therapy in a uni-
versity outpatient clinic drop out unim-
proved during the first dozen meetings.3
Conversely, patients who in the first 12
meetings achieve high group popularity, or
who show high satisfaction with the group,
are more apt to show clinical improvement
at the end of 50 meetings.4 These observa-
tions suggest the rationale of therapeutic in-
tervention early in the life of the group. A
recent study demonstrating that a pre-
therapy "role induction interview" could
beneficially influence the early course and
outcome of individual therapy provided ad¬
ditional impetus to this study.5 If a cogni¬
tive orientation to therapy can so affect a
dyadic interactional system, then its impli¬
cations for group therapy are exciting be¬
cause of the early group culture building
which, once set into motion, is powerful and
relatively irrevocable.
Recent developments in the entire field of
psychotherapy also suggest that a cognitive
orientation of the prospective patient might
beneficially influence therapy. Clearly there
is an important trend toward demys¬
tification of the psychotherapeutic process,
toward a defrocking of the therapist, toward
a more collaborative venture between pa¬
tient and therapist. An ego-based psycho-N
Submitted for publication March 31, 1967.
From the Department of Psychiatry, Stanford
University School of Medicine, Palo Alto, Calif.
Reprint requests to Stanford Medical Center, Palo
Alto, Calif 94304 (Dr. Yalom).
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015
therapeutic framework has reoriented us to
an appreciation of the patient's adaptive
coping mechanisms, and toward recruitment
of these processes in the therapeutic frame¬
work.6 The utilization of patient as thera¬
pist in staffless groups in many psychiatric
hospitals, the programming of leaderless
outpatient groups,7 the instrumented Hu¬
man Development Institute programs for
interpersonal learning (unpublished materi¬
al by J. Berlin and B. Wyckoff), the use
of peers or near peers as therapists,8 and the
many responsible programs in progress for
training nonprofessionals in psychotherapy
are all manifestations of the démystification
trend. Psychotherapy, these approaches may
argue, is a rational, teachable process the
efficacy of which is enhanced rather than
impaired by explication.
Another source of impetus for this study
comes from the nonclinical small group
field. Human development laboratories or
sensitivity training groups have, for many
years, augmented the group process with ex¬
planatory reading material and periodic lec-
turettes designed to provide a cognitive map
for the proceedings.9 Although the compara¬
bility of these groups with therapy groups is
still controversial, it is undeniable that there
exists much overlap in structure and process
between them.
These converging factors, then—from
theory, research, and clinical practice—all
suggest the importance and timeliness of a
controlled investigation into the effects on
patient behavior and attitudes of a systema¬
tic explicatory session prior to the beginning
of group therapy. This explicatory session
instructs patients to engage in here-and-now
interaction focusing on relationships among
group members and, in addition, was de¬
signed to increase faith in group therapy
and attractiveness of the therapy group. The
experimental groups, which had an explica¬
tory session, were compared with control
groups which had no such session. Three hy¬
potheses were studied.
 Hypothesis 1.—Patients in the experi¬ formed of the immediate availability of
mental groups were expected to have greater group therapy. Excluded from consideration
faith in group therapy than patients in con¬ flagrantly psychotic patients, addicts,
were
trol groups. alcoholics, and patients with mental retarda¬
Hypothesis 2.—Patients in the experi¬ tion or organic syndromes.
mental groups were expected to have greater The (»therapists of the six groups were 12
attraction (cohesiveness) to their groups first-year residents. During the first seven
than in control groups. months of their residency they had had an
Hypothesis 3.—Patients in the experi¬ intensive group therapy training course con¬
mental groups were expected to engage in sisting of weekly didactic sessions and clini¬
more here-and-now discussion of interper¬ cal seminars, and a 50-hour sensitivity train¬
sonal relations within the group than pa¬ ing group experience. They had observed
tients in control groups. experienced group (»therapists conduct ap¬
proximately 20 group therapy meetings
Method (with a similar patient population) and par¬
ticipated in postgroup "rehash" sessions.
Summary of Research Design.—Sixty pa¬ The general orientation of the program was
tients on the group therapy waiting list of a a dynamic, interactional one. One of the
university outpatient clinic were interviewed therapist's chief tasks was formulated as
by one of us (I. D. Y.) prior to the first meet¬ helping the group mature into the thera¬
ing with their group therapists, and were peutic agent. Emphasis was placed on the
randomly assigned to one of two conditions. importance of immediate expression of feel¬
The experimental subjects were given a sys¬ ings and here-and-now interaction, Therapy
tematic 25-minute preparatory lecture on centered on the understanding and correc¬
group therapy, whereas the control subjects,
tion of parataxic distortions among the
although seen by the same researcher for an group members and of general maladaptive
equal period of time, did not receive the interpersonal stances.
group orientation lecture. The patients then Following their sensitivity group experi¬
went into six therapy groups—three groups ence, the residents selected (»therapists.
of experimental subjects and three groups of The six (»therapist pairs were then divided,
control subjects. These groups were studied on the basis of the faculty's general assess¬
for the first 12 meetings to determine what ment of their competence, into two equal
differences, if any, resulted from our manip¬ groups of three (»therapists each. Three of
ulation. Throughout this study the group these cotherapist pairs were randomly se¬
therapists were totally unaware of the na¬ lected to lead the three groups of experimen¬
ture or design of this research. tal subjects, and the other three cotherapist
Clinical Setting.—Our sample was repre¬ pairs to lead the three control groups. It is
sentative of the population in the Stanford important to repeat that the therapists were
University outpatient clinic and has been never aware of the nature of this research.
described in detail in previous reports.3·4 It is common clinic practice for one of us
The mean age was 28, with a range from 18 (I. D. Y.) to see group patients in a pre¬
to 49. The population, largely from the mid¬ liminary screening interview. Postgroup pa¬
dle socioeconomic class, was a sophisticated, tient questionnaires and tape-recordings of
well educated one; 94% had graduated from the meetings for research purposes are also
high school and 72% had had some college part of routine clinic practice and have been
education. Fees ranged from $1 to $10 per continuously utilized in the clinic for four
session. Diagnostic classification primarily years.
indicated characterologic or neurotic disor¬ Procedure.—The 60 patients on the group
ders. Occasionally a patient was labeled waiting list were randomly divided into two
as a borderline schizophrenic or psycho¬ equal groups of experimental and control
physiological reaction. Approximately two subjects. All 60 were asked to come to the
months before the groups were scheduled to clinic to meet with the associate director of
begin, a group therapy waiting list was the clinic (I. D. Y.) for registration and for
formed. All patients applying for therapy a discussion regarding their request for
during this time were considered for group group therapy. The first patients were seen
therapy. Local referring sources were in- in small groups of three to five, but schedul-

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015

 ing made this design impractical people in their lives now, as well as with people
pressures
and the great majority of patients were seen they had yet to meet.
individually. The patients were advised that the way they
The experimental patients were given a could help themselves most of all was to be
25-minute group preparatory lecture. The and honest direct with their feelings in the
group at that moment, especially their feelings
major goals of this presentation were: (1) towards the other group members and the ther¬
To enhance the patient's faith in group apists.
This point was emphasized many times
therapy. (2) To enhance the attractiveness and was referred to as the "core of group thera¬
(cohesiveness) of the patient's specific py." They were told that they may, as they de¬
group. (3) To direct the patient toward con- velop trust in the group, reveal intimate aspects
frontive, here-and-now interaction in the of themselves, but that the group was not a
group. (The greatest proportion of the pre¬ forced confessional and that people had
paratory session was devoted to this goal.) differential rates of developing trust and re¬
To accomplish these goals the orientation vealing themselves. It was suggested to them
presented the patients with a rational de¬ that the group could be seen as a forum for
scription of the practice, the theoretical ba¬ risk-taking, and that as learning progressed,
new types of behavior might be tried in the
sis, and the results of group therapy. Possi¬
ble sources of stress were identified. Finally, group setting.
Certain stumbling blocks were predicted. Pa¬
patients were instructed to discuss their feel¬ tients were forewarned about a feeling of puz¬
ings about other group members. The pres¬ zlement and discouragement in the early meet¬
entation was informal and questions were
ings; it would, at times, not be apparent how
solicited and answered. A descriptive ac¬ working on group problems and intragroup re¬
count of the orientation follows. lationships could be of value in solving the
A brief explanation of the interpersonal problems which brought them to therapy. This
theory of psychiatry began with the statement puzzlement, they were told, was to be expected
that everyone seeking help in group therapy in the typical therapy process, and they were
had in common the basic problem of encounter¬ strongly urged to stay with the group and not
ing difficulty in establishing and maintaining to heed their inclinations to give up therapy.
close and gratifying relationships with others, They were told that many patients found it
although each group member manifested his painfully difficult to reveal themselves or to ex¬
problems differently. They were reminded of press directly positive or negative feelings. The
the many times in their lives that, undoubtedly, tendencies of some to withdraw
emotionally, to
they wished to clarify a relationship, to be real¬ hide their feelings, to let others express feelings
ly honest about their positive or negative feel¬ for them, or to form concealing alliances with
ings with someone and get reciprocally honest others were discussed. The therapeutic goals of
feedback from others. The general structure of group therapy were described as ambitious: we
society, however, does not often permit totally desired to change behavior and attitudes many
open communication. The therapy group, it years in the making; treatment, therefore,
was emphasized, is a special microcosm where would be gradual and many, many months in
this type of honest interpersonal exploration duration. We discussed with them the
vis-a-vis the other members is not only permit¬ velopment of feelings of frustration or annoy¬
likely de¬
ted, but encouraged. If people are conflicted in ance with the therapist, how they would in vain
their methods of relating to others, then ob¬ expect answers from him. The source of help
viously a social situation which encourages would be primarily the other patients. We
honest interpersonal explorations can provide knew, we told them, of their difficulty in ac¬
them with a clear opportunity to learn many cepting this fact, of their probably wondering
valuable things about themselves. It was em¬ "How can the blind lead the blind?"
phasized to them that working on their rela¬ Next they were told about the history and
tionships directly with other group members development of group therapy. We described,
would not be easy; in fact, it might be very for example, how group therapy passed from a
stressful; but it was of the utmost importance stage during the second world war when it was
because if one could completely understand valued because of its economic feature in allow¬
and work out one's relationships with the other ing psychiatry to reach a large number of pa¬
group members, there would be an enormous tients, to its present position in the field where
carry over. They would then find pathways to it is clearly seen as having something unique to
more rewarding relationships with significant offer and is often the treatment of choice. Re-

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015

 suits of psychotherapy outcome studies were groups with a total of 20 control subjects,
cited in which group therapy was shown to be and three groups with a total of 23 experi¬
as efficacious as any mode of individual thera¬ mental subjects. The (»therapists, of course,
py. An outcome project4 at Stanford conducted made the final decision as to whether an as¬
last year was described in which it was shown
that a very high proportion of group therapy
signed patient should begin therapy in his
group. Seventeen (nine experimental and
patients who remained in group therapy for a
year were significantly improved. Our remarks
eight control patients) did not begin group
in this area were focused toward instilling faith therapy: either they were not accepted by
in group therapy and dispelling the false notion the group therapists, or they themselves
of many patients that group therapy is "second elected not to begin.
class therapy," to be used when individual Each pair of (»therapists was supervised
treatment is unavailable. one hour a week by a highly experienced
Lastly, we attempted to enhance the attrac¬ clinician. Each supervisor was assigned two
tiveness of their particular group. Before the groups, an experimental and a control
interview they were asked to hand in two lists group. Everyone involved—therapists, pa¬
of traits: one characteristic of people whom tients, and supervisors—was unaware of the
they liked, and another characteristic of those nature of the research. The residents knew
whom they disliked. During the interview they that some type of research was in progress,
were told that we would place them in a group
which was maximally compatible with them,
because we collected tapes of each meeting
and that we would use their Usta in this task.
and postgroup questionnaires; but they were
This device, although a well-accepted small not aware, even a year later, that there had
group research technique, was the only part of been
experimental manipulation.
an
the group preparatory interview which was de¬ Comparison Measures.—The six groups
ceptive. were studied throughout their first 12 meet¬
The control patients were also seen by the ings. Six different measures
were selected to
same interviewer for 25 minutes; registration
compare the three experimental groups with
data and some historical material were ob¬
the three control groups.
tained. They were then given a brief "orienta¬
tion" to group therapy; however, all the points Hill Interaction Matrix.—Inasmuch as
covered were facts that they would have our major emphasis in orienting patients
learned at their first therapy meeting. For ex¬ was on how they should behave in the group
ample, we told them about the size of the sessions, our main concern was with how
group, the number of therapists, the probable they did, in fact, behave in the groups. The
age range of the group members, the length of Hill Interaction Matrix10 method of scoring
the meetings, and the fees. They were informed interaction in therapy groups was well-suited
that attendance was very important for their to measure the effects of our manipulation.
therapy and, like the experimental group, they While we cannot describe the scoring sys¬
were urged not to drop out but to make a com¬ tem in detail here, a brief description is in
mitment to attend at least a dozen meetings be¬ order to understand the results. Hill's scor¬
fore attempting to evaluate the value of the
ing method consists of a 4 X 4 matrix, which
group to them. Both the experimental and con¬ is shown in Table 1. All statements are
trol patients were informed that a group thera¬
pist would call them within two weeks. scored and placed in one of 16 cells. For
The next step was patient assignment. purposes of clarity we have used a different
The clinic psychiatric social worker was giv¬ lettering system from the one described in
the Hill manual. Hill described a fifth row,
en two patient lists, A (control) and a
(experimental), as well as a list of three Responsive, which is intended for groups of
chronic regressed patients but which is not
pairs of A group therapists and three pairs
group therapists; they were then asked applicable
of to our population.
to assign the patients to the appropriate Hill considers the speculative and con-
groups. The social worker was not aware of frontive statements (rows Y and Z) to be
the identity of the A or condition. He at¬ "work" statements because someone is tak¬
tempted to fill one A or group at a time, ing the role of a patient and actively seeking
striving for an equal male-female, single- self-understanding. He considers the asser¬
married ratio. Finally there were three tive and conventional statements (rows W

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015

 and X) to be "non-work" because the pa¬ Table 1.—Modified Hill Interaction Matrix
tient role is avoided. 3 4
12
Before analyzing the Hill ratings, the 16 Relation-
types of statements were divided into three Topic Group Personal ship
major categories: (1) directly oriented state¬ W Conventional 1W 2W 3W 4W
ments (cells 2W, 2X, 2Y, 2Z, 4W, 4X, 4Y, X Assertive IX 2X 3X 4X
3Y
4Z) ; (2) indirectly oriented statements Y Speculative
Confrontive
1Y
1Z
2Y
2Z 3Z
4Y
4Z
(cells 3X, 3Y, 3Z) ; and (3) nonoriented The columns refer to types of content:
statements (cells 1W, IX, 1Y, 1Z, 3W). 1. Topic statements are about topics of general in¬
The directly oriented category is the one terest exclusive of the group or its members.
2. Group statements deal with the group as an entity.
most relevant to our preparatory session. If 3. Personal statements are about a group member
this sessionwere effective, then we would independent of his relationships with other members of
the group.
anticipate that the three experimental 4. Relationship statements deal with relationships
between members and between a member and the
groups would score higher than the three group.
control groups in this category, which con¬ The rows refer to levels of work:
W. Conventional statements are socially appropriate
sists of group and relationship statements. for any group. They consist largely of social pleasantries
Since the preparatory session did not spe¬ and discussions of one's problems in a conventional,
socially appropriate manner without putting oneself in
cifically stress different work levels (rows), a patient role.
all levels of group and relationship state¬ X. Assertive statements are argumentative and hos¬
tile. They often involve blaming others -ather than
ments were placed in this category. oneself for problems, and so evade the patient role.
Y. Speculative statements deal with therapeutic issues
The indirectly oriented category consists in a speculative intellectual way.
of all personal statements made by a mem¬ Z. Confrontive statements confront patients or the
group with aspects of their behavior usually avoided,
ber with the exclusion of superficial, conven¬ 3nd with some documentation to allow reality testing.
tional statements; we speculated that the
experimental groups would score higher groups had been oriented when they scored
than the control groups in this category. Al¬ the interaction.
though the preparatory session did not spe¬ Interaction was scored from tape record¬
cifically orient patients to speak on personal ings of the second, fifth, and twelfth meet¬
levels, we reasoned that the decreased un¬ ings of each of the six therapy groups. The
certainty and increased trust in group thera¬ second meeting was chosen because first
py would indirectly permit them to speak meetings of therapy groups are often ritual¬
more freely about personal problems with ized introductions with little opportunity
less need to engage in superficial conven¬ for serious interaction. The twelfth meeting
tionalities. In combining assertive with spec¬ was the last one scored because we had asked
ulative and confrontive levels we differ subjects to stay through 12 meetings before
somewhat from Hill, who would call asser¬ deciding whether to remain or leave their
tive level interaction nonwork because the groups. This procedure, it was hoped, would
patient is avoiding the patient role. How¬ Table 2.—Postgroup Questionnaire
ever, we felt that assertive statements can in¬
dicate emotional involvement and are often 1. I found the meeting today to be
good bad
part of serious therapy. .

2. Compared with how much you would tell a casual

The nonoriented category consisted of all friend, how frankly did you express your feelings about
the remaining statements, mostly superficial other group members?
very frank not frank
interaction often referred to as group flight .

3. Compared with how much you would tell a casual

or resistance. If the preparatory session friend, how much of your private life did you tell the
were effective in enabling the experimental group today?
a great deal none at all
groups to engage in group work more quick¬
.

4. How would you rate your mood right now?

ly, then we would expect them to score low¬ a. angry .
not angry
tense
er in this category. b. relaxed .

c. discouraged . hopeful
Three of us were trained in scoring inter¬ d. involved with others.. .withdrawn from others
action with the Hill Interaction Matrix and 5. The group worked together today
notatali very well
had achieved an 80% agreement with Hill's
.

6. I made progress ¡n achieving my goals in therapy

criterion test prior to scoring these proto¬ today
deal
cols. The three raters did not know which none . a great

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015

 minimize the number of dropouts during the
research period.
The middle half-hour of each meeting was
scored. Two raters listened to each
recording and peached a consensus on the
scoring of each statement. A scorable state¬
ment consisted of one person's continuous
talk within one of the Hill categories. Thus
a long, uninterrupted soliloquy by one pa¬
tient entirely in one category would be
scored only once. If he were interrupted by
someone else, even if the interrupter were
also speaking in the same category, the in¬
terruption itself would be scored, as would
the resumption after it. If talk shifted to an¬
other category and then returned, the other
category would be scored, as would resump¬
tion of the first category. Since most state¬
ments were terminated by another person's
speaking rather than the same speaker shift¬
ing to another category, the total number of
statements scored in a half-hour period is a
rough index of the amount of interaction
during the period.
Each rater scored an equal number of ori¬
ented and nonoriented groups for each
meeting studied.
Postgroup Questionnaires.—At the end of
every therapy meeting the patients filled out
a questionnaire consisting of nine items,
each answered on a 7-point scale; this ques¬
tionnaire is reproduced in Table 2.
Cohesiveness Questionnaire.—A ten-ques¬
tion cohesiveness questionnaire, described
elsewhere,11 was filled out by the patients
at the end of the fourth, eighth, and twelfth
meetings.
Faith in Group Therapy Questionnaire.—-
Before therapy (immediately after the
group preparatory or control interview),
and once again after the twelfth meeting,
the patients answered two questions: (1)
What percent of people who start group
therapy do you think are helped by group
therapy? (2) How long do you think it takes
the average person to get definite benefit
from group therapy?
Attendance and dropout records were
kept.
Clinical data were available on each
group from tapes and from a summary of
each meeting dictated by the therapists.
Results
Hill Interaction Matrix.—The three ex-
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015
perimental group scores were combined for
each meeting, as were the scores for the
three control groups. The percentage of
statements occurring in the three statement
categories for each of the meetings are
shown in Fig 1.
The percentage of directly oriented state¬
ments is higher for the experimental than
for the control groups on all three of the
rated meetings, whereas the percentage of
nonoriented statements is lower for the ex¬
perimental groups on all three meetings.
The indirectly oriented statements show a
more complex pattern, with the oriented
groups higher on meetings two and five, but
lower on meeting 12.
Since the three-statement categories form
a rank order from oriented to indirectly ori¬
ented to nonoriented, a Mann-Whitney two-
sample rank test was used to test the
differences between the experimental and
control groups for weeks two and twelve.
The differences on week five were in the ex¬
pected direction, but did not reach statisti¬
cal significance. The lack of significant dif¬
ferences on week five raised the possibility
that the effect of the orientation was curvi¬
linear over time: high at the beginning and
later in the group, but overshadowed by oth¬
er factors around the fifth meeting. It is also
possible that the lack of significant results
was due to sampling error.
In order to investigate the alternatives
further, we scored the sixth meetings of all
groups. (Raters were, again, not aware of
which were the experimental and which the
control groups.) The results are shown in
Fig 2 and Table 4. In meeting six the experi¬
mental groups had more directly and indi¬
rectly oriented statements and fewer non¬
oriented statements than did the control
groups. These differences are in the same
direction as in meeting five and are now sta¬
tistically significant using the Mann-Whit¬
ney rank test. This indicates that the lack of
significant differences between experimental
and control groups in the fifth meeting were
not indicative of a curvilinear effect of the
preparatory session over time and may have
been due to sampling error.
In order to test in more detail how the
three statement categories differed between
the oriented and nonoriented groups, the
2X3 contingency tables in Tables 3 and 4
 were each partitioned into three 2 2 2 ta¬ Week 1
bles. The results, shown in Table 5, tell us Il Experimental qroups
60
more about the differences over time be¬ 1 I Control groups
tween the oriented and nonoriented groups.
All three 2 are significant for week two, 40
indicating that the experimental groups ex¬
ceed the control groups to a greater degree
20
on oriented than on nonoriented statements
and have a greater proportion of both direct¬
ly and indirectly oriented statements than of § O
nonoriented statements. This is exactly Week 5
what we would have expected from our ma¬ 60
nipulation: its strongest effects were shown
-

on directly oriented, and the next strongest

on indirectly oriented statements. £40
O
+-
Week five has no statistically significant
differences among the three statement cate¬ O 20
gories, whereas week six again shows a sig¬ c
nificantly greater proportion of both directly
and indirectly oriented statements than of g 0
Week \Z
nonoriented statements for the experimental 60
groups. However, counter to our expecta¬
tions that the largest difference between ex¬
perimental and control groups would be 40
with oriented statements, the experimental
groups exceeded the control groups to a 20
greater degree on indirectly oriented than on
oriented statements.
Week twelve is similar to week six, except Indirectly Non¬
Oriented
that this time the difference in proportion of statements oriented oriented
statements statements
indirect vs nonoriented statements is not
significant for the two types of groups. Fig 1.—Percent of oriented, indirectly oriented, and
nonoriented statements made in weeks two, five, and
The most consistent finding over the twelve.
weeks is that, for the oriented groups, the
proportion of directly oriented statements is
significantly greater than the proportion of we would expect five of them to exceed this
nonoriented statements. The results with probability level. We therefore must con¬

the indirectly oriented statements are more clude that these two differences may have
equivocal and, since they do not follow a been due to chance.
consistent pattern, are difficult to interpret.Cohesiveness Questionnaire.—Cohesive¬
Postgroup Questionnaires.—The experi¬ ness scores of the experimental and control
mental and control groups were compared groups were compared for the fourth, eighth,
on each of the nine postgroup questionnaire and twelfth meetings. No statistically sig¬
items for each of the first 12 meetings. Out nificant differences were found between the
of these 108 comparisons, two had probabili¬ two groups on any of these meetings.
ty levels of less than 0.05: at meeting ten, Faith in Group Therapy.—Immediately
members of oriented groups rated their mood following the orientation session, (prior to
as more tense than did members of non¬ therapy) and again at the twelfth meeting,
oriented groups, and at meeting five, mem¬ all patients were asked to estimate the per¬
bers of oriented groups rated themselves as centage of people helped by group therapy
making more progress toward their goals and the amount of time required for benefit.
than did members of nonoriented groups. The Mann-Whitney U-test was used as a
However, if this number of comparisons test of statistical significance. There were no
were to be made from a random population, statistically significant differences between

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015

 Table 3.—Statements in the Three Categories
tor Experimental and Control Groups on
Weeks 2, 5, and 12
Statements
Groups Oriented Indirect
Experimental 67 104
Control 17 53
Experimental 37 84
Control 33 85
55
Experimental 118
Control 62 96
*
P<0.05, Mann-Whitney two-sample rank test
rected for ties.
the experimental and control groups prior to
therapy. At the twelfth meeting, however,
the experimental patients estimated signifi¬
cantly shorter times required for benefit
from group therapy (P < 0.05). They also
estimated that a larger percentage of pa¬
tients was helped by group therapy than did
the control group, but this difference did not
reach statistical significance (P < 0.10).
Attendance and Dropout Records.—The
experimental and control groups did not
differ significantly in the number of drop¬
outs. At the end of ten months, ten experi¬
mental and ten control patients had dropped
out from group therapy. The mean stay of
the experimental patient was longer (18.2
meetings) than for the controls (11.7 meet¬
ings). This difference was not, however, sig¬
nificant. The early attendance pattern is in
itself quite interesting. All 43 patients were
strongly urged to remain in therapy for at
least 12 weeks, and only 14% of the group
members dropped out during the first 12
meetings—less than half the number of
dropouts often presents a formidable ob¬
stacle in group therapy research. The tech¬
nique of urging patients to remain in therapy
for a minimum set period may prove useful
Non¬
to other workers.
oriented Week
Comment
124 2*
118
143
5
Hypothesis 1 (greater faith in group
173
41
therapy among experimental subjects) re¬
12* ceived some support from our findings.
109
cor¬ Hypothesis 2 (greater cohesiveness
among the experimental subjects) was not
supported by our findings.
Hypothesis 3 (greater here-and-now inter¬
personal interaction among experimental
subjects) was strongly supported by our
findings.
To interpret these findings let us review
those aspects of the preparatory session rele¬
vant to each hypothesis.
Hypothesis 1.—In the preparatory session
we attempted to enhance the patients' faith
in group therapy by citing encouraging out¬
come studies, by describing the unique fea¬
tures of group therapy, and, no doubt, by
transmitting the interviewer's enthusiasm
for the modality. There is considerable re¬
search evidence that positive structuring of
the patients' initial expectations beneficially
influences the course and outcome of indi¬
vidual therapy,12·13 and our results sug¬
gest that a similar process may occur in
Table 4.—Statements in the Three Categories
for Experimental and Control Groups on Week 6*
Statements

dropouts observed in the same population in Groups Oriented Indirect Nonoriented

previous studies.3 The high rate of early Experimental 139 153 92
Control 83 55 123
c *
P<0.05 Mann-Whitney two-sample rank test cor¬

Week 6 rected for ties.

§60
+-
O
I 1
Experimental groups
I I Control groups
. - Table 5.—x~ Values tor Partitioned Tables
(
Comparing Experimental and Control Groups
40
+- Week
o
+-
Statements 2 5 6 12
%20 Oriented vs indirect 4.85* 0.20 5.91* 27.93:
Oriented vs non¬
0L oriented 20.91t 1.33 17.22; 47.88t
Oriented Indirectly Non¬ Indirect vs non¬
statements oriented oriented oriented 8.75f 0.88 41.42 í 2.86
statements statements
* P<0.05.
Fig 2.—Percent of oriented, indirectly oriented, and t P<0.01.
nonoriented statements made in week six. î P<0.001.

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015

 group therapy. We tested for this effect by
asking the patients (pretherapy, and again
at the twelfth meeting) to estimate the per¬
centage of patients helped by group therapy
and the duration of time required. At the
twelfth meeting the experimental groups
tended to be more optimistic than the con¬
trol groups. goals (group integrity, construction of an
Hypothesis 2.—In the preparatory inter¬ atmosphere of trust, and an interactional
view we also attempted to increase the mem¬ confrontive focus) and the individual goals
bers' satisfaction with their groups by telling of the patient (relief of suffering). Part of
them that, on the basis of their question¬ the task of the preparatory interview was to
naire data, they would be placed in a maxi¬
mally compatible group. However, the cohe¬
siveness questionnaire scores (obtained at
fourth, eighth, and twelfth meetings) of the
experimental groups were not significantly
higher than those of the control groups. This
procedure, one which has traditionally been
successful in laboratory research, may have
failed in this research for several reasons.
First, the emphasis on cohesiveness in the
preparatory interview was very weak, con¬
sisting of only a single sentence. Secondly,
the cohesiveness questionnaire, adapted
from laboratory small-group research, may
have overemphasized being comfortable in
the group, and the more interactive task-ori¬
ented experimental groups may well have
been less comfortable for the members,
though more cohesive or binding. It is inter¬
esting to note that two of the control groups
fragmented shortly after the end of the for¬
mal study, losing three members each be¬
tween the 13th and 16th meetings. The im¬
pact and stress of the early meetings of the
experimental groups may well have neutral¬
ized the weak initial favorable expectation
we implanted. In fact, Goldstein14 cites evi¬
dence that individuals who are exposed to
more stress than anticipated may react with
hostility at the disconfirmation of their ex¬
pectations.
Hypothesis 3.—The third goal and major
emphasis of the preparatory interview was
to increase the development of interpersonal
interaction in the group. Our method was to
provide a cognitive structure for the patient.
We clarified the rationale of group therapy
by briefly explaining the interpersonal theo¬
ry of psychiatry and the advantages of an
interactional focus in the group. Through
this explanation, and through predictions of
anticipated obstacles, we attempted to de-
crease anxiety. In addition, we attempted to
clarify the goals of therapy.
One important source of perplexity and
discouragement for patients in the initial
stages of group therapy is a perceived goal
incompatibility. They will often be unable
to discern the connection between group
disconfirm the apparent incompatibility,
and to clarify how these goals are, in fact,
confluent. The preparatory interview, fur¬
thermore, attempted to clarify expected role
behavior. The patients were presented with
unambiguous guidelines for their behavior
in the group. Types of efficacious and self-
defeating behavior were concretely described,
and the rationale behind our value judge¬
ments was explained. The ambiguity sur¬
rounding the role of the therapist was also
lessened by outlining his goals and purpose
in the group.
The importance of clarity of goals and
role expectations in effective group function¬
ing has been demonstrated by an abundance
of small group research, recently re¬
viewed.15 In laboratory groups, increased
clarity of goals and increased explication of
the methods of goal attainment result in
greater member attraction to the group,
increased sympathy for group emotions,
decreased intermember hostility, increased
intermember influencability, increased moti¬
vation, increased member security, in¬
creased efficiency, and decreased member
frustration.1619 Ambiguous group-member
role expectations reduce group satisfaction
and group productivity and increase mem¬
ber defensiveness. Many psychotherapy and
group dynamic studies have demonstrated
that the more discrepant the member's ex¬
pectancies of the group leader's role, the
"less the attraction to the group, the less the
satisfaction of group members, and the more
the strain or negative affect between leader
and led or therapist and patient."20
The results of our study indicate that pa¬
tients systematically prepared for interac¬
tional group therapy, will engage themselves
more quickly in the therapeutic task than
patients not so prepared. Considerable evi-

Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015

 dence, cited above, suggests that increased guity, absence of cognitive anchoring, and
clarity of goals and paths to attain these
goals, as well as increased clarity of role ex¬
pectations, result in conditions more condu¬
cive to effective therapy. Why, then, are pa¬
tients not routinely prepared for group
therapy in a systematic manner? In fact,
all group therapists do attempt to clarify
the therapeutic process and expected role be¬
havior, and the difference between therapists
or between therapeutic schools is largely
a difference in timing and style of prepara¬
tion. Some group therapists initially pre¬
pare the new patient by providing him with
written material about group therapy,21 or
by having him hear a tape of a model group
therapy work meeting (as noted by B. Ber-
zon in an oral communication, May 1965),
or by having him attend a trial meeting,22
or by a long series of individual intro¬
ductory lectures or an instrumented pro¬
gram of therapy and insight aids.23·24
However, even the therapists who deliber¬
ately abrogate initial preparation and orien¬
tation of the patient nevertheless have in
mind goals and preferred modes of group
procedure which eventually are transmitted
to the patient. By subtle, or even subliminal,
verbal and nonverbal reinforcement, even
the most nondirective therapist structures
his group so that inevitably it adopts his val¬
ue system of high and low priority content
and process.25·26 This was illustrated by
the fact that even the control groups consist¬
ently increased in the percentage of oriented
statements throughout the 12 meetings. (Fig
1 and 2).
If we accept the research evidence that
the group therapist's goals and preferred
procedural paths to goal attainment are ulti¬
mately transmitted to the group, why, then,
is an initial systematic preparation of pa¬
tients uncommon in group therapy prac¬
tice?
Some therapists hold that ambiguity of
both patient and therapist role expectation
is a desirable condition of the early phases
of therapy.27·28 If one accepts the premise
that the development and eventual resolu¬
tion of patient-therapist transference distor¬
tions is a key curative factor in therapy,
then it follows that one should seek, during
the early stages of therapy, to enhance the
development of transference. Enigma, ambi-
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015
frustration of conscious and unconscious
wishes all facilitate a regressive reaction to
the therapist and help create an atmosphere
favorable for the development of transfer¬
ence toward the therapist and parataxic dis¬
tortions toward other group members. These
therapists wish to encourage regressive phe¬
nomena and the emergence of unconscious
impulses so they may be identified and
worked through in therapy.29
Other therapists, who deemphasize the
centrality of the patient-therapist relation¬
ship in group therapy and look to total
group forces as the therapeutic agent, also
argue against the initial clarification of
group goals and process. If, as Bion states,30
the chief task of the group is to analyze its
own tensions, then the anxiety stemming
from initial uncertainty surrounding the ex¬
pected group process forms the initial group
task. Others31 point out that the initial anx¬
iety encourages the group toward an early
problem-solving culture and eventual group
autonomy; one cannot, it is argued, establish
group solutions by edict. Slavson insists that
initial anxiety is a desirable feature, since it
delays the development of group cohesive¬
ness.32 The group thus does not develop a
degree of comfort incompatible with thera¬
peutic work.
An authoritative discussion of these issues
is difficult because of the dearth of relevant
sound research. The identification and the
rank ordering of the curative factors in
group therapy is entirely problematic. Some
pertinent research studies4·33·84 suggest that
the important curative forces are total
group and interactive in nature; for exam¬
ple, group support, group cohesiveness, and
popularity in the group. Nevertheless, there
are many different group therapies, and it is
possible that the relative importance of the
curative forces varies depending on the ther¬
apist's goals and techniques. Thus there
may exist well thought out and appropriate
reasons for deliberate perpetuation of initial
unclarity. However, if interpersonal interac¬
tion is considered a desired condition in
group therapy, and we contend that it is in
the great majority of present-day group
therapy, then our research demonstrates
that a systematic preparatory interview will
 facilitate the appearance of interaction in
therapy groups.
A systematic preparation for group thera¬
py by no means implies a structuring of the
group experience. We do not espouse didac¬
tic or directive group therapy, but, on the
contrary, suggest a technique which will en¬
hance the formation of a freely interacting
autonomous group. By averting lengthy rit¬
ualistic behavior in the initial sessions, and
by diminishing initial anxiety stemming
from unclarity, the group is enabled to
plunge into work more quickly. In our view,
anxiety caused by deliberate unclarity is not
necessary to prevent the groups from becom¬
ing too socially comfortable. Our patients
are conflicted in their interpersonal relation¬
ships and any groups—-for example our
three experimental groups which have an
increased rate of interpersonal interaction—
will continually present challenging and
anxiety-fraught interpersonal confronta¬
tions. Therapy groups which are too com¬
fortable are groups which engage in flight
from the task of direct interpersonal con¬
frontation.
We would suggest that anxiety stemming
from unclarity of the group task, process,
and role expectations in the early meetings
of the therapy group may, in fact, be a de¬
terrent to effective therapy. Considerable
evidence exists that, although anxiety with
accompanying hypervigilance may be adap¬
tive, excessive degrees of anxiety will ob¬
struct coping with stress.35·36 In his review
of evidence supporting the concept of an ex¬
ploratory drive, White37 notes that anxiety
and fear retard learning and result in de¬
creased exploratory behavior to an extent
correlated with the intensity of the fear. It
has been postulated that man has a primary
drive to explore and master his environ¬
ment, and that there is an intrinsic pleasure
and positive reinforcing value in the investi¬
gation of environment, the experiencing of
competence, and the production of an effect
on the environment.38 The concept that
learning is facilitated by frustration has
been challenged by many psychotherapists
who conceptualize the patient-doctor rela¬
tionship as a therapeutic alliance. Kardi-
ner39 states that it is the successful and
gratifying experiences, not the frustrations,
that will lead to integration.
The early group therapy experience is a
strange, usually threatening social environ-
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015
ment for our patients. For learning to occur,
and for positive reinforcement of adaptive
interpersonal behavior to transpire, the
patient must feel that he is effectively in¬
vestigating and producing a purposeful, ap¬
propriate effect on his environment. If, as
research evidence holds, anxiety is the enemy
of environmental exploration,37 then a reduc¬
tion of the extrinsic anxiety of uncertainty
should enhance the formation of an atmos¬
phere conducive to interpersonal explora¬
tion. If patients are unclear about the long-
range goals of the group and the stepping
stones to those goals, then the possibility
exists that constructive behavior will not
be recognized as such by the patient. Poten¬
tially adaptive exploration may not be grati¬
fying or reinforcing for the patient who sus¬
pects that this behavior is irrelevant, or even
counter, to therapeutic objectives.
In conclusion, there is considerable evi¬
dence from a number of sources that exces¬
sive initial anxiety, frustration, and unclari¬
ty may inhibit learning and be disconsonant
with successful psychotherapy. In interac¬
tional group therapy, in which the thera¬
peutic process is considered to be mediated
through free interpersonal interaction and
the therapeutic relationship is conceptual¬
ized as a therapeutic alliance, we demon¬
strated the feasibility and efficacy of a sys¬
tematic preparation for therapy. Through a
pretherapy explication of the group process
and expected role behavior the therapy
group is more quickly able to engage in the
therapeutic task.
Summary
In controlled investigation the effects of
a
a pretherapy preparatory session on the ear¬
ly course of group therapy are studied. The
findings indicate that the preparatory session
increases the development of interpersonal
interaction, ie, the discussion of intermember
relationships in the group. In addition, there
was some evidence that patients' faith in
group therapy was strengthened by the pre¬
paratory session. There was no effect of the
experimental procedure on the patients' at¬
traction to their particular groups.
Implications of these findings for the
theory and practice of group therapy were
discussed. A preparatory interview clarify¬
ing group process and role expectations can
enhance the efficacy of interactional group
therapy by hastening the appearance of
effective levels of group communication.
 This research was partially financed by a Stan¬
ford University general research support grant, and
by NIMH grant No. MH 8304.
William F. Hill, PhD, and Donald Staight, MSW,
assisted in this research.
References
1. Bales, R.F.: "The Equilibrium Problem in
Small Groups," in Parsons, T.; Bales, R.F.; and
Shils, E. (eds): Working Papers in the Theory of
Action, Glencoe, Ill: Free Press, 1953.
2. Jacobs, R.C., and Campbell, D.T.: The Perpet-
uation of an Arbitrary Tradition Through Several
Generations of a Laboratory Microculture, J Ab-
norm Soc Psychol 62:649-658, 1961.
3. Yalom, I.D.: A Study of Group Therapy Drop-
outs, Arch Gen Psychiat 14:393-414, 1966.
4. Yalom, I.D., et al: Prediction of Success in
Group Therapy, Arch Gen Psychiat 17:159-168, 1967.
5. Hoehn-Saric, R., et al: Systematic Preparation
of Patients for Psychotherapy, J Psychiat Res
2:267-281, 1964.
6. Bandler, B.: Health Oriented Psychotherapy,
Psychosom Med 21:176-181, 1959.
7. Berzon, B.: The Self Directed Therapeutic
Group, Int J Group Psychother 14:366-369, 1964.
8. Goodman, G.: "Companionship as Therapy:
The Use of Non-Professional Talent," in Hart, J.T.,
and Tomlinson, T.M. (eds): New Directions in
Client-Centered Psychotherapy, New York: Hough-
ton-Mifflin Co., to be published.
9. Bradford, L.P.; Gibb, J.R.; and Benne, K.D.:
T-Group Theory and Laboratory Method, New
York: John Wiley and Sons, Inc., 1964.
10. Hill, W.F.: HIM: Hill Interaction Matrix, Los
Angeles: Youth Study Center, University of South-
ern California, 1965.
11. Yalom, I.D., and Rank, K.: Compatibility and
Cohesiveness in Therapy Groups, Arch Gen Psy-
chiat 15:267-276, 1966.
12. Goldstein, A.D., and Shipmen, W.G.: Patient
Expectancies, Symptom Reduction and Aspects of
the Initial Psychotherapeutic Interview, J Clin Psy-
chol 17:129-133, 1961.
13. Frank, J.: The Dynamics of the Psychothera-
peutic Relationship, Psychiatry 22:17-39, 1959.
14. Goldstein, A.P.; Heller, K.; and Secrest, L.B.:
Psychotherapy and the Psychology of Behavior
Change, New York: John Wiley and Sons, Inc.,
1966, p 405.
15. Goldstein, A.P.; Heller, K.: and Secrest, L.B.:
Psychotherapy and the Psychology of Behavior
Change, New York: John Wiley and Sons, Inc.,
1966, pp 376-377.
16. Rauer, B.H., and Reitsema, J.: The Effects of
Varied Clarity of Group Goal and Group Path Upon
the Individual and His Relation to His Group, Hu-
man Relations 10:29-45, 1957.
17. Wolfe, D.M.; Snock, J.D.; and Rosenthal,
R.A.: Report to Company Participants at 1960 Uni-
versity of Michigan Research Project, Ann Arbor,
Mich: Institute of Social Research, 1961, in Gold-
stein et al: Psychotherapy and the Psychology of
Behavior Change, New York: John Wiley and Sons,
Inc., 1966, p 391.
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of Michigan User on 06/14/2015
18. Cohen, A.R.; Stotland, E.; and Wolfe, D.M.:
An Experimental Investigation of Need for Cogni-
tion, J Abnorm Soc Psychol 51:291-294, 1955.
19. Cohen, A.R.: "Situational Structure, Self-
Esteem and Threat-Oriented Reactions to Power,"
in Cartwright, D. (ed) : Studies in Social Power, Ann
Arbor, Mich: Research Center for Group Dynamics,
1959, pp 35-52.
20. Goldstein, A.P., et al: Psychotherapy and the
Psychology of Behavior Change, New York: John
Wiley and Sons, Inc., 1966, p 405.
21. Martin, H., and Shewmaker, K.: Written In-
structions in Group Therapy, Group Psychother
15:24, 1962.
22. Bach, G.R.: Intensive Group Psychotherapy,
New York: Ronald Press, 1954.
23. Malamud, D.I., and Machover, S.: Toward
Self-Understanding: Group Techniques in Self Con-
frontation, Springfield, Ill: Charles C Thomas Pub-
lishers, 1965.
24. Bettis, M.D.; Malamud, D.I.; and Malamud,
R.F.: Deepening a Group's Insight Into Human Re-
lations, J Clin Psychol 5:114-122, 1949.
25. Murray, E.J.: A Content Analysis for Study
in Psychotherapy, Psychol Monogr 70 No. 13, 1956.
26. Goldstein, A.P., et al: Psychotherapy and the
Psychology of Behavior Change, New York: John
Wiley and Sons, Inc., 1966, pp 422-423.
27. Horwitz, L.: Transference in Training Groups
and Therapy Groups, Int J Group Psychother
14:202-213, 1964.
28. Wolf, A.: "The Psychoanalysis of Groups," in
Rosenbaum, M., and Berger, M. (eds): Group Psy-
chotherapy and Group Function, New York: Basic
Books, Inc., 1963, pp 273-328.
29. Schiedlinger, S.: The Concept of Repression in
Group Psychotherapy, read before American Group
Psychotherapy 24th annual conference, New York,
January, 1967.
30. Bion, W.R.: Experiences in Groups, New
York: Basic Books, Inc., 1959.
31. Whitaker, P.S., and Lieberman, M.A.: Pscyho-
therapy Through the Group Process, New York:
Atherton Press, 1964, p 208.
32. Slavson, S.: A Textbook in Analytic Group
Psychotherapy, New York: International Universi-
ties Press, 1964.
33. Dickoff, H., and Lakin, M.: Patients' Views of
Group Psychotherapy: Retrospections and Interpre-
tations, Int J Group Psychother 13:61-73, 1963.
34. Kapp, F.T., et al: Group Participation and
Self-Perceived Personality Change, J Nerv Ment
Dis 139:255-265, 1964.
35. Janis, I.L.: Psychological Stress: Psychoana-
lytic and Behavioral Studies of Surgical Patients,
New York: John Wiley and Sons, Inc., 1958.
36. Basowitz, H., et al: Anxiety and Stress, New
York: McGraw-Hill Book Co., Inc., 1955.
37. White, R.W.: Motivation Reconsidered: The
Concept of Competence, Psychol Rev 66:297-333,
1959.
38. Hendrick, I.: Instinct and the Ego During In-
fancy, Psychoanal Quart 11:33-58, 1942.
39. Kardiner, A., and Spiegel, H.: War Stress and
Neurotic Illness, New York: Hoeben Co., 1947.