Interpersonal Problems and the Perception of ... - SAGE Journals

SMALL GROUP RESEARCH MacNair-Semands, Lese / GROUP / April THERAPY 2000

INTERPERSONAL PROBLEMS AND THE PERCEPTION OF THERAPEUTIC FACTORS IN GROUP THERAPY REBECCA R. MACNAIR-SEMANDS University of North Carolina at Charlotte

KAREN P. LESE University of San Diego

Fifteen therapy and support groups in university counseling centers were studied to assess shift in therapeutic factors over time and the relationship between therapeutic factors and interpersonal problems. The levels of therapeutic factors tended to increase over time. Furthermore, significant associations were formed between certain interpersonal problems and perceptions of the therapeutic factors in group therapy. Implications for the conceptualization of clinical dynamics in group therapy and theoretical understanding of group development are discussed.

For many decades, group therapists and researchers have been informed by the concept of therapeutic factors (Yalom, 1995), a theoretical constellation of the curative aspects of a group. Therapeutic factors are described by Yalom (1985, 1995) as representing different parts of the change process, actual mechanisms of change, and conditions for change. Such curative aspects of group are believed to operate in every type of therapy group and are described as the core elements beneficially affecting client growth in groups. Although therapeutic factors are a widely accepted theoretical conAUTHORS’ NOTE: Special appreciation is given to the staff at the Virginia Commonwealth University Counseling Center, Texas Tech University Counseling Center, and the University of North Carolina at Charlotte Counseling Center for help with data collection. This article is dedicated to the memory of John G. Corazzini, Ph.D., group psychotherapy mentor for both of the authors. SMALL GROUP RESEARCH, Vol. 31 No. 2, April 2000 158-174 © 2000 Sage Publications, Inc.

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struct in group therapy literature, research of these factors has been imprecise and variable (Scheidlinger, 1997). The lack of an empirically driven instrument assessing the therapeutic factors has seriously limited the quality of group therapy process research (Bednar & Kaul, 1994; Crouch, Bloch,& Wanlass, 1994; Dies, 1993). Several authors have put forth hypotheses about how the therapeutic factors should shift with group development. However, there are few empirical studies of the therapeutic factors as a function of time in group. Yalom (1985) suggested that instillation of hope, universality, and imparting information (guidance) should be more highly valued in the early stages of a group’s development. Yalom also proposed that cohesiveness and altruism should be continually important throughout the group. Burton (1982) postulated that hope, universality, and guidance dominate the group’s first developmental stage, which he labeled the engaged stage of group. Burton proposed that during the group’s second stage (labeled differentiation), vicarious learning, self-disclosure, and interpersonal learning would be central. During his individuation stage (stage three), he expected altruism, catharsis, acceptance (cohesion), and self-understanding to predominate. To investigate the hypotheses of both Yalom (1985) and Burton (1982), Kivlighan and Goldfine (1991) employed an indirect method of studying therapeutic factors through critical group incidents (Bloch & Reibstein, 1980). Using empirical measures that assessed both therapeutic factors and group development (Group Climate Questionnaire; MacKenzie, 1983), the authors explored how the factors varied with stage of group. They found that catharsis and guidance (similar to Yalom’s imparting information) increased across the stages, and that acceptance (similar to Yalom’s cohesiveness) was most important at both the engaged and individuation stages. Several researchers have empirically examined whether certain therapeutic factors are more valued at different stages, rather than whether the factor actually increased with time (Kivlighan & Mullison, 1988). In one empirical study, Butler and Fuhriman (1983) found that clients’perceptions of the importance of acceptance (the

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equivalent of Yalom’s [1985] cohesiveness), insight, and interpersonal learning increased as a function of time in group therapy. MacKenzie (1987) found that acceptance (cohesion), instillation of hope, and universality were prioritized early in the group’s development, whereas interpersonal learning, vicarious learning, and self-understanding were seen as more important later in the group. Lastly, Freedman and Hurley (1980) revealed that only two factors, catharsis and interpersonal learning outputs, were perceived as more helpful with increasing group experience. From the previous divergent results for both perceived value and perceived existence of the factors, it is clear that replication in therapeutic factor group research has been rare. A clear limitation contributing to such diverse findings is the lack of a consistent measure of the therapeutic factors. INTERPERSONAL PROBLEMS AND THE THERAPEUTIC FACTORS

One of the assumptions of group therapy is that participation in a group will influence group members’ interpersonal styles such that they can improve functioning in intimate relationships. Yalom’s (1985, 1995) concept of the social microcosm suggests that group members’ interpersonal styles and problems will not only emerge behaviorally but also will affect how the member perceives and experiences the group. Yalom’s social microcosm concept is directly connected to one of the core tenets of Sullivan’s (1953) interpersonal theory: that people will perceive others in ways that maintain their interpersonal problems. Consistent with this assumption, it has been empirically demonstrated that client interpersonal style influences the endorsement of therapeutic factors (Kivlighan & Goldfine, 1991; Kivlighan & Mullison, 1988). Furthermore, in group therapy, the members’ perception of the therapeutic factors is related to outcome (Lieberman, Yalom, & Miles, 1973). Limitations of past studies include the use of the critical incident method to rate and classify incidents into one of the therapeutic factors, which is an indirect method of measuring the factors. Kiv-


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lighan and Mullison (1988) observed that such nominal data do not lend themselves to sophisticated analyses, and that interval measures could provide more precise descriptions of the relationship between time and perception of therapeutic factors. They also note that past hypotheses about the relation between therapeutic factors and group development are too simplistic given the multistage models of group development accepted today, as researchers tend to believe the factors should wax and wane throughout various group stages. The Therapeutic Factors Inventory (TFI) was designed to provide a comprehensive measure to determine presence or absence of therapeutic factors in a particular group (Lese & MacNairSemands, 1997, 2000; MacNair-Semands, 1997). The TFI assesses group member perceptions of the degree of presence of the 11 therapeutic factors described by Yalom (1995). Scales of the TFI include instillation of hope, universality, imparting information, altruism, corrective reenactment of the primary family group, development of socializing techniques, imitative behavior, interpersonal learning, cohesiveness, catharsis, and existential factors. Difficulties with previous instruments attempting to measure the therapeutic factors have been noted elsewhere (Fuhriman, Drescher, Hanson, Henrie, & Rybicki, 1986; MacKenzie, 1983; MacNair-Semands, 1997). There is little psychometric support for Yalom’s q-sort measure: Freedman and Hurley (1980) found that less than half of Yalom’s (1985) factor scales demonstrated adequate alpha reliabilities, indicating generally weak internal consistency. PURPOSE OF THE STUDY

Past research has explored how valued or important the various therapeutic factors have been to group members, but often has not simply studied the degree to which such factors are present. In addition, little research has examined individual differences and perception of therapeutic factors. The first purpose of the present study was to demonstrate how the assessment of therapeutic factors in a group change over time. It was hypothesized that the perceived

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therapeutic factors would strengthen with time in the group. Second, the study examines how perceived therapeutic factors may be related to member interpersonal difficulties. Due to the lack of consistent findings about the relationship between perceived therapeutic factors and interpersonal problems, hypotheses in this area could not be formed based on past literature. Thus, to meet the second goal of the study, we decided to explore the relationships empirically. A third goal of the present study was to continue to provide construct validation for the TFI, following past evidence of internal consistency and test-retest reliability for the TFI (Lese & MacNair-Semands, 2000).

METHOD PARTICIPANTS

Fifteen therapy and support groups at three university counseling centers in the Southeast and Southwest were targeted to request participation. Each group had 5 to 10 members, and met for 1½ hours weekly. The study was approved by the university committees for research with human subjects at each location, and all participants gave informed consent. The age of clients ranged from 18 to 47 years, with a mean age of 25.66 (SD = 6.41). Thirty-four clients were female (68%) and 16 were male (32%), reflecting a typical gender distribution of students receiving services at these agencies. Eighty-six percent of participants were Caucasian (n = 43) and 4% each were African American, Asian American, biracial, or “other.” Only group members who had not previously completed the TFI in earlier studies, and those able to complete all questionnaires at both administrations were included, resulting in a total of 49 participants with complete data. MEASURES

The TFI. The TFI is a comprehensive, empirically based measure used to determine the perceived presence or absence of thera-


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peutic factors in a particular group. Therapeutic factors were defined based on Yalom’s (1995) concepts and descriptions, and items were generated based on this formulation. To ensure appropriate and representative content, doctoral psychologists with specialties in group psychotherapy originally generated items independently. The 174 items (15 to 19 for each scale) were then either revised or discarded as inadequate based on the following factors: clarity, lack of correspondence with the factor definition, and redundancy. Following item analysis and internal consistency analysis (Lese & MacNair-Semands, 2000), the scale retained 99 items with a 7-point Likert-type scale. The TFI demonstrated adequate internal consistency and test-retest reliability with the exception of the recapitulation of the family subscale, which had a testretest reliability that was unacceptable (Lese & MacNair-Semands, 2000). For the present study, alpha coefficients were performed for all 11 therapeutic factor scales of the TFI for both administrations. Time 1 TFI results indicated moderate to high alpha reliabilities for the 9-item scales: altruism, .77; catharsis, .85; cohesiveness, .89; existential factors, .83; instillation of hope, .92; imitative behavior, .82; imparting information, .73; interpersonal learning, .70; recapitulation of the family, .76; socializing techniques, .80; and universality, .81. Time 2 results also indicated moderate to high alpha reliabilities for the 9-item scales, with the exception of imitative behavior: altruism, .91; catharsis, .87; cohesiveness, .90; existential factors, .92; instillation of hope, .94; imitative behavior, .54; imparting information, .70; interpersonal learning, .89; recapitulation of the family group, .82; socializing techniques, .87; and universality, .86. Inventory of Interpersonal Problems (IIP). The IIP (Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988) is a 127-item scale with a 5-point Likert-type scale. Participants are asked to describe the amount of distress they have experienced for each interpersonal problem. The first portion (H scales) of the IIP contains 78 items beginning with the phrase, “It is hard for me to . . . .” The second portion (T scales) has 49 items beginning with the phrase, “I am too . . . .” The IIP has demonstrated acceptable reliability and valid-

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ity (Horowitz et al, 1988; Horowitz, Rosenberg, Ureno, Kalehzan, & O’Halloran, 1989). To avoid the possibility that IIP subscales reflect a general complaint factor or the clients’general tendency to report distress, ipsative scoring was used as recommended by Horowitz et al (1988). Factor analyses of the IIP have found a large general first factor that reflects individual differences in readiness to endorse complaints (Bartholomew & Horowitz, 1991). An ipsative subscale score expresses a subscale score as a deviation from the person’s own mean response to all 127 items of the IIP; it demonstrates whether a particular subscale score reflects higher than average distress for that particular person. Therefore, each set of subscale scores was ipsatized to eliminate variance due to an overall complaint factor. Each subscale score was expressed as a deviation from the subject’s mean, and thus reflects the extent to which the interpersonal problems were more or less problematic for that individual. PROCEDURE

Participants volunteered time at the end of a group session to complete the TFI at two occasions near the start and finish of the semester. To vary the time of IIP administration based on length of time in group, 21 students were asked to complete the IIP at first administration of the TFI (Time 1, 42%), and 29 students were asked at the second administration (Time 2, 58%). At first administration, group members had been attending an average of 3 to 6 group sessions; at second administration, most participants had attended approximately 8 to 12 group sessions. The average time in between administrations was 6 group sessions (range = 4 to 7).

RESULTS

As predicted, the levels of therapeutic factors increased as a function of time in group therapy. Analysis of the means revealed a significant increase (p < .05) for universality, t (45) = –2.65; instillation of hope, t (45) = –2.16; imparting information, t (47) = –2.85;


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TABLE 1: Paired T Test and Means of Therapeutic Factor Scores at Times 1 and 2 Time 1

Time 2

Therapeutic Factor

Mean (SD)

Mean (SD)

t Score

df

Universality* Hope* Imparting information* Altruism Recapitulation of the family* Socialization Imitative behavior Interpersonal learning Cohesiveness* Catharsis* Existential factors

46.26 8.94 44.26 10.17 34.10 8.44 46.13 7.13 40.15 8.49 45.58 7.59 35.76 8.41 43.57 7.18 47.77 9.70 45.29 9.79 45.04 7.84

50.13 7.74 48.42 9.32 36.52 8.02 48.38 8.57 44.19 8.91 47.54 8.42 40.00 13.65 46.23 9.20 52.17 8.00 49.02 8.72 47.68 8.66

–2.65 –2.16 –2.85 –1.71 –2.64 –1.39 –1.92 –1.61 –2.93 –2.61 –1.76

45 45 47 46 44 47 44 45 47 46 44

*p < .05.

recapitulation of the family, t (44) = –2.64; cohesiveness, t (47) = –2.93; and catharsis, t (46) = –2.61, from first to second TFI administration. All of the other therapeutic factors also increased with time in the predicted direction, but not to a statistically significant degree (see Table 1 for means). Correlations were performed for the IIP scales and the TFI scales. At Time 1 on the TFI, significant correlations revealed a relationship between difficulty being submissive (i.e., acting overly dominant with others) and the perception of altruism (r = –.42, p < .005), socialization (r = –.40, p < .005), imitative behavior (r = –.37, p < .05), and interpersonal learning (r = –.40, p < .005) in the group. Additionally, significant positive correlations were found between the perception of altruistic behaviors in the group and having problems related to lack of assertiveness (r = .36, p < .05), and being too responsible (r = .30, p < .05). Thus, those participants who complained of being overly dominant tended to see the group as less altruistic, less apt to promote socializing, having less modeling through imitative behavior, and as giving less interpersonal feedback (see Table 2). At the second administration of the TFI, significant correlations were found between interpersonal problems related to difficulty

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NOTE: H. = Hard for me to be. * p < .05. ** p < .005.

Instillation of hope Imparting information Altruism Recapitulation of the family Socialization Imitative behavior Interpersonal learning Cohesiveness Catharsis Existential factors Universality

Therapeutic Factor .02 –.18 .36* –.05 .17 .17 .17 .17 –.11 .12 .09

H. Assertive –.09 –.09 –.23 .11 .08 –.07 –.18 –.14 .03 –.26 .00

H. Sociable –.21 .05 –.42** –.14 –.40** –.37* –.40** –.17 –.08 –.22 –.25

H. Submissive .11 .06 –.28 .18 .04 –.15 –.03 –.10 .07 .10 –.15

H. Intimate

–.04 –.03 .30* .08 .14 .17 .26 .09 –.07 .02 .16

Too Responsible

.01 –.21 –.02 –.11 –.15 .03 .09 –.01 –.00 .06 .02

Too Controlling

TABLE 2: Correlations Between Therapeutic Factors Inventory at Time 1 and Ipsitive Inventory of Interpersonal Problems Scale Scores


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being submissive and perceiving the group as instilling hope (r = –.32, p < .05), recapitulating family dynamics (r = –.37, p < .05), and engaging in imitative behavior (r = –.46; p < .005). Thus, those stating they were overly dominant indicated that they perceived less recapitulation of family dynamics and less imitative behavior in the group. Additionally, an association was found between students’ describing themselves as too responsible and the perception of cohesiveness in group (r = –.33, p < .05). Group members who saw themselves as too responsible viewed the group as less cohesive. See Table 3 for correlations.

DISCUSSION

The results of the present study demonstrate several principles related to group psychotherapy. The first finding reveals that as members spend time participating in group therapy, the strength of the therapeutic factors change. A second series of findings illustrates aspects of the dynamics of members’ perceptions of the therapeutic factors; specifically, that such perceptions may be consistent with group members’ interpersonal problems. Finally, the results provide construct validation of the TFI measure and further our understanding of how the TFI can illuminate perceptions of the group experience in a format beneficial to group leaders. The experience of continuing group therapy participation is apparently related to a significantly enhanced feeling of being similar to others in a group (universality), an increase in hopefulness that problems will be resolved, and a stronger sense that group members are imparting information used to alleviate distress. The perception that family roles are being reenacted in the therapy group, the sense of group cohesiveness, and the perception of disclosing with a cathartic process also all increased as a function of time in group therapy. The results support past research demonstrating that guidance (imparting information) and catharsis increased in importance across stages (Kivlighan & Goldfine, 1991). Similar to Butler and Fuhriman (1983), this study found that cohesiveness (acceptance) increased in importance as a function of

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NOTE: H. = Hard for me to be. *p < .05. ** p < .005.

Instillation of hope Imparting information Altruism Recapitulation of the family Socialization Imitative behavior Interpersonal learning Cohesiveness Catharsis Existential factors Universality

Therapeutic Factor .21 –.16 .25 .23 .23 .31 .19 .27 .11 .19 .26

H. Assertive .02 –.10 .12 .28 .22 .04 .19 .02 .24 .28 .02

H. Sociable –.32* .00 –.20 –.37* –.22 –.46** –.23 –.05 –.16 –.27 –.21

H. Submissive –.05 .02 –.10 –.02 .00 –.24 –.01 –.02 –.04 –.04 –.05

H. Intimate

–.22 –.04 –.17 –.01 –.18 –.01 –.11 –.33* –.23 –.12 –.29

Too Responsible

–.09 .25 –.20 –.26 –.22 –.07 –.28 –.09 –.14 –.19 –.09

Too Controlling

TABLE 3: Correlations Between Therapeutic Factors Inventory Scales at Time 2 and Ipsative Inventory of Interpersonal Problems Scale Scores


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time in group therapy. Most significant, the present findings support the notion that as group members move through the stages of group development together, many of the therapeutic factors strengthen and solidify. Consistent with Yalom’s social microcosm concept, group members tended to perceive others in ways that were consistent with their interpersonal problems. It had previously been found that such interpersonal problems influenced the perceived value of therapeutic factors (Kivlighan & Goldfine, 1991); the present results demonstrate that these problems also influence the individual’s perceptions of the actual level of therapeutic factor present in the group. Correlations performed on the IIP scales and the TFI scales revealed that those who found it hard to be assertive and persons who described themselves as too responsible for others perceived the group as significantly higher on the altruism factor at the first administration. It is possible that those suffering distress due to a lack of assertiveness or a heightened sense of responsibility for others expected less from the group members at the commencement, thus viewing them as more altruistic when helping or kindness was evident in the group. It is also possible that “overly responsible” members interpreted their own behaviors and intentions as highly altruistic, given that such members reported dynamics of responding to others with heightened responsibility. Participants with elevated “hard to be submissive” scores have been described as dominant in personality through circumplex analysis with the IIP (Kivlighan & Angelone, 1992). Such dominant participants viewed the group in the first stage as lower on the factors of interpersonal learning, imitative behavior, socialization skills, and altruism. Dominant styles of interpersonal interacting may lead to an exaggerated sense of conflict and a dismissal of what the client is receiving from the group. Because dominant members may be intimidating or less emotionally vulnerable, they may accurately experience a lower level of altruism directed toward them, which may influence their perception of how the group as a whole is responding to each other. Similarly, dominant members may appraise the group as having less interpersonal learning and fewer socialization skills and imita-

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tive behaviors because they are not accepting the feedback in the domains of interpersonal behaviors that such clients are likely to need the most. This notion is supported by Horowitz et al. (1988), who found that certain interpersonal problems were more resistant to treatment. For example, the authors found that people with intimacy problems on the IIP made less change in therapy than people with problems in assertiveness did. They noted that intimacy problems may be more complex, producing a threatened sense of autonomy or entrapment which might impair relationships during therapy. It is also possible that these members need a higher level of reassurance and support to accurately recognize the therapeutic factor of altruism. Toward the end of the group therapy experience, a relationship became evident between members who described themselves as dominant and had a tendency to view the group as lower on the factors of instillation of hope, recapitulation of the family, and imitative behavior. Kivlighan and Angelone (1992) demonstrated that group members who perceived themselves as too dominant experienced the group climate as avoidant and tense. Such avoidance and tension may lead to a denial of similarities between the group and the family of origin, a decrease in the desire to learn through imitation, and a decrease in openness to hopeful messages. Members in the Kivlighan and Angelone study who perceived themselves as assertive also perceived the group climate as less engaged, conflictual, and anxious. The present study indicates that more dominant members may have failed to fully perceive some of the therapeutic components of the therapy group toward the end of the sessions. In a related fashion, the group members in this study who described themselves as too responsible at the end of the group sessions perceived less cohesiveness in the group. Such members may have believed that they carried the responsibility of building cohesion in the group and that they failed in such an endeavor. In contrast, they may have been disappointed in the lack of responsiveness to their overly responsible style. Further research would help delineate such dynamics, particularly in the relationships across interpersonal style that did not reach the level of significance but demonstrated trends. For instance, clients with difficulty being


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assertive had stronger endorsement of the therapeutic factors in general, and those describing themselves as controlling tended to report a lower level of therapeutic factors. The present results provide tentative support for the construct validity of the TFI. The current project found relationships consistent with previous research on the therapeutic factors (Butler & Fuhriman, 1983; Kivlighan & Goldfine, 1991). Furthermore, the results indicating that therapeutic factor perceptions are related to group members’interpersonal problems provide additional support for the validity of the TFI. Continued construct validity studies are currently in progress using additional group climate measures. A strength of the present study is that perceptions of the therapeutic factors were measured at three different counseling centers in ongoing therapy groups rather than less intensive group experiences. However, several limitations also deserve mention. Most of the groups had open membership. Because members began their group participation at different times, it was not possible to completely standardize administration of the questionnaires. Limited power due to small sample size is an additional limitation. As is typical for group studies with smaller sample sizes, the statistical tests were only sensitive to detecting large differences between groups. This element of the present study makes it difficult to determine whether the nonsignificant trends that were obtained reflected an actual pattern in the data. Furthermore, few validity data are available on the TFI. This project follows papers that delineated the development of the TFI (Lese & MacNair-Semands, 1997; MacNair-Semands, 1997) and reliability results (Lese & MacNair-Semands, 2000). The increasing strength of the factors with time and the correlation patterns of TFI subscales with interpersonal problems support validity at this stage of instrument development. However, conclusions of this study must be evaluated with the caveat of limited validity in mind. It is important to be cognizant of several characteristics of the present study. First, stage of group development was not measured in this study; thus, whether therapeutic factors corresponded to particular group stages was not researched. Associations between therapeutic factors and stage of group can only be discussed in

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terms of time and group experience without implying particular group dynamics or development. Second, the format of the TFI asks participants to rate their experience without outside validation, reflecting the participants’ subjective experience. This format limits the way in which its results can be interpreted. This structure is intentional: Lieberman (1983) notes that because behavioral observations cannot directly assess insight or the development of a participant’s altered perspective, most investigators have chosen to study the therapeutic mechanisms with a direct inquiry of participants’ personal experiences. However, in future research, behavioral measures using external criteria (i.e., Beck, Dugo, Eng, & Lewis, 1986) to assess therapeutic factors could be combined with the direct approach of the TFI to provide construct validation for the factors in a multimethod approach.

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Freedman, S. M., & Hurley, J. R. (1980). Perceptions of helpfulness and behavior in groups. Group, 4, 51-58. Fuhriman, A., Drescher, S., Hanson, E., Henrie, R., & Rybicki, W. (1986). Refining the measurement of curativeness: An empirical approach. Small Group Behavior, 17, 186-201. Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureno, G., & Villasenor, V. S. (1988). Inventory of Interpersonal Problems: Psychometric properties and clinical applications. Journal of Consulting and Clinical Psychology, 56, 885-892. Horowitz, L. M., Rosenberg, S. E., Ureno, G., Kalehzan, B. M., & O’Halloran, P. (1989). Psychodynamic formulations, consensual response method, and interpersonal problems. Journal of Consulting and Clinical Psychology, 57, 599-606. Kivlighan, D. M., & Angelone, E. O. (1992). Interpersonal problems: Variables influencing participants’ perception of group climate. Journal of Counseling Psychology, 39, 468472. Kivlighan, D. M., & Goldfine, D. C. (1991). Endorsement of therapeutic factors as a function of stage of group development and participant interpersonal attitudes. Journal of Counseling Psychologist, 38, 150-158. Kivlighan, D. M., & Mullison, D. (1988). Participants’ perception of therapeutic factors in group counseling: The role of interpersonal style and stage of group development. Small Group Behavior, 19, 452-468. Lese, K., & MacNair-Semands, R. R. (1997, August). Therapeutic Factors Inventory: Development of a scale. Poster session presented at the annual meeting of the American Psychological Association, Chicago. Lese, K., & MacNair-Semands, R. R. (2000). The Therapeutic Factors Inventory: Development of a scale. Manuscript submitted for publication. Lieberman, M. A. (1983). Comparative analyses of change mechanisms in groups. In R. R. Dies & K. R. MacKenzie (Eds.), Advances in group psychotherapy: Integrating research and practice (pp.159-170). Madison, CT: International Universities Press. Lieberman, M. A., Yalom, I. D., & Miles, M. D. (1973). Encounter groups: First facts. New York: Basic Books. MacKenzie, K. R. (1983). The clinical application of a group climate measure. In R. R. Dies & K. R. MacKenzie (Eds.), Advances in group psychotherapy: Integrating research and practice (pp.159-170). Madison, CT: International Universities Press. MacKenzie, K. R. (1987). Therapeutic factors in group psychotherapy: A contemporary view. Group, 11, 26-34. MacNair-Semands, R. R. (1997). Using new instruments to enhance group therapy. In J. Corazzini (Chair), Integral features of group psychotherapy. Symposium conducted at the annual meeting of the American Psychological Association, Chicago. Scheidlinger, S. (1997). Group dynamics and group psychotherapy revisited: Four decades later. International Journal of Group Psychotherapy, 47, 141-159. Sullivan, H. S. (1953). The interpersonal therapy of psychiatry. New York: W. W. Norton. Yalom, I. D. (1985). The theory and practice of group psychotherapy (3rd ed.). New York: Basic Books. Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books.

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Rebecca R. MacNair-Semands is a licensed psychologist and Group Services coordinator at the University of North Carolina at Charlotte Counseling Center. She received her Ph.D. from Virginia Commonwealth University. She has published on such topics as group therapy assessment, AIDS prevention, stress appraisal, and the ethical dilemmas of abuse. Karen P. Lese is coordinator of training at the University of San Diego Counseling Center. She received her Ph.D. from Virginia Commonwealth University. Her publications and professional interests include group psychotherapy, psychological trauma, and applications of feminist and multicultural theory.