Molyn Leszcz on Group Psychotherapy

Molyn Leszcz on Group Psychotherapy

by Victor Yalom
Molyn Leszcz, co-author (with Irvin Yalom) of the 5th edition of The Theory and Practice of Group Psychotherapy, discusses the core principles and techniques of this powerful but underutilized modality.
Filed Under: Group Therapy


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Core principles of Group Therapy

Victor Yalom: To get started, Molyn, can you give a general definition of what group therapy is, and what are some of the core principles of the way group therapy works? I know those are broad questions.
Molyn Lesczc: I think that the first statement to make is that group therapy is not a monolith; it is a range of different approaches that utilize the group. Some groups tend to be more skill-building and psycho-educational, for example, and use factors of peer presence support, camaraderie, and economy of scale to deliver an intervention. Then there are therapists who use the group as an agent for change, in which we aim to make better use of the processes of interaction, feedback, and learning from one another that occur within the group.
VY: That, in and of itself, is quite a different idea in terms of how we tend to think about therapy. Most of us are trained initially as individual therapists, so we think of the therapist and the therapeutic relationship as the agent of change. Here, we’re suddenly thinking the whole group is part of the change process.
ML: Absolutely. The group is an entity of its own shaped by the multiple relationships that occur between people in the group. The complexity is so much greater in groups like this, but the power comes from that as well.  The bread-and-butter group therapy is the kind of work that we describe in The Theory and Practice of Group Psychotherapy, where
The group becomes a social microcosm: an opportunity for people to learn about the interpersonal underpinnings of their psychological distress.
the group becomes a social microcosm; an opportunity for people to learn about the interpersonal underpinnings of their psychological distress; an opportunity for interpersonal learning—insight, feedback—and behavioral skill acquisition.

I see group therapy, really, as the ultimate integrative model, because it’s a treatment that provides an opportunity for people to gain insight, self-awareness, and behavioral skill and practice. It integrates cognitive, emotional and behavioral elements.
I think we’re always aspiring to do that in our work, but group therapy really delivers on that as effectively as any treatment.

VY: Right. Of course, you’re referring to the text originally written by my father, Irvin Yalom. And you came aboard as co-author for the latest, the Fifth Edition, of that book.
ML: That’s correct.
VY: He primarily espouses an interpersonal model of group psychotherapy.  Could you say a few words to summarize the core concepts of this approach?
Sure. First, let me say that the interpersonal approach has become more popular of late, and it’s important to distinguish the interpersonal approach to group therapy and other versions that have more to do with IPT—the Myrna Weissman approach to interpersonal therapy—which is non-here-and-now, but rather more skill-building and educational. I’m going to focus on the interpersonal model of group that that was really pioneered by your father. I had the great privilege of working with him, and then contributing to the Fifth Edition of this text.
In essence, what that work does is build upon a long tradition that focuses on our need, as relationally determined people, to engage, and how our engagement in our contemporary world is shaped by early life experiences.
Harry Stack Sullivan, through his influence on other people in Baltimore at Johns Hopkins, had a big role, as you know, in your dad’s view. He impacted Frieda Fromm-Reichmann and Jerome Frank. And your father took it to a remarkably accessible level. In essence, how I understand it is like this: every person operates in this world with a certain kind of roadmap, which consists of our beliefs about ourselves and the world that emerge from early life experience, and the interpersonal behaviors that follow from those beliefs.
If we are healthy and resilient with good self-esteem, then our behaviors reinforce adaptive beliefs about ourselves, and we engage a healthy, productive loop in our relational world.
VY: Right. And speaking of self-esteem, I recall some statement by Sullivan that our own sense of esteem is really, in some sense, a collective mirroring of the feedback we perceive from others.
ML: That’s right, the reflective self-appraisals.
VY: Do you agree with that, or do you think that’s overstated?
ML: Absolutely.
VY: Isn’t there also something we bring to our personhood that we’re born with?
Certainly there are constitutional and temperamental factors. How our early life environment reacts to that and reinforces that, I think, is pivotal.
You can take a highly energetic child—temperamentally a bit reckless, aggressive, assertive—and in a family that is able to corral that and harness it and see it as self-determination and strength of will, that person will grow up with a stronger sense of self and self-esteem than a child that grows up in a family where that is viewed as being burdensome, a nuisance, and something that a depressed parent doesn’t have time for.
So the pathogenic beliefs, which are the starting point of the roadmap, are shaped by early life events, the environment, culture, personal psychology, family psychology, temperament, constitution—all these things together.
But they have powerful influence, because they then shape the interpersonal behavior that follows:we seek what is familiar, not necessarily what nourishes our growth. Group therapy becomes a very powerful way to illuminate that link between pathogenic beliefs and interpersonal behaviors. And many contemporary models of psychotherapy echo that.
So an energetic, maybe excitable child in an optimal environment would be supported, maybe gradually shaped, so that he can succeed in the world; and in another set of circumstances, his development might go awry.          
So, group therapy, of course—or any form of therapy—tries to deal with the situations where something goes awry, so they’re not functioning fully effectively, and also having some internal problems—distress—about what’s happening in their life.
ML: Right.
VY: If you start with this interpersonal model that asserts that we’re basically social animals, how does group address the situations when things go awry?
ML: I think the group therapy addresses that by creating an environment in which people are able to bring themselves as they genuinely are in the world at large. That’s the social microcosm. The group would not be useful if what happened in the group didn’t reflect what happens in people’s lives at large.
VY: The social microcosm refers to the idea that however people are in the world, including their behaviors that cause them problems, will get played out or enacted in the group.
And the more you’re able to get people to look at interpersonal processes and communication in the here-and-now, the more the microcosm comes to life.
If you had a highly structured group where people were given specific tasks, you’d have much less opportunity for people’s interpersonal style and interpersonal processes to emerge. I’m sure you’re familiar with the background at National Training Laboratories, the original work by Kurt Lewin in the late ‘40s.
VY: It was a bit before my time, but I’ve heard of NTL.  Weren’t they referred to as T-groups, or training groups?
ML: Yes, they were training groups for executives. In essence, they were being taught how to be better leaders. At the end of the day, all of the facilitators would meet and talk about the group dynamics, and how hard it was to get this guy to see things from other people’s perspective and the like. What emerged then is that executives found out that they were being discussed in the evenings. They said, “Give us access to that information.” So that really became the start of the encounter group mentality, where people were given feedback in the moment, rather than a focus on the transmission of content material alone.
VY: And I assume they found that feedback useful.
ML: Well, they found it useful and challenging.

Working in the Here-and-Now

VY: Getting back to the social microcosm, say I have a client who's aggressive, has difficulty maintaining relationships, or another client who is a people-pleaser, never gets his or her needs met. A naïve reaction might be, "Well, we don't want them to repeat that behavior in the group. We want them to change it." But this model is saying, "First, we want to see what that behavior looks like."
ML: That's right. It begins by manifesting itself. We obviously don't want it to persist, and we're looking for every opportunity for change. But people are more likely to make changes when they have hard evidence for what the problem is.

A classic example is the man who reports in the group how his wife is always hard on him, critical, and he doesn't feel he gets a break. In fact, it's illuminated even in the Schopenhaeur Cure video to a certain degree, with Gil and Pam. If you're not careful, the group may sympathize with him and give him advice such as, "You're married to a miserable woman. Get away from her."

Whereas if you look at what's happening in the here-and-now and ask this very powerful here-and-now question—if you asked the women in the group, "Based upon on what you know of this man, in his time in the group, what would you think it would be like to be married to him?"—then you get the feedback about what it would be like being married to an inanimate object:"He seems like a decent guy, but if I was married to him, I'd be withering on the vine because he's so unresponsive and gives so little of himself." It's an intervention that your dad has used, and I've used many times.
VY: You're referring, of course, to this video demonstration that we're just releasing, which was an enactment of the characters in my father's book, The Schopenhaeur Cure, which occurs largely in the context of a therapy group.
ML: Exactly. So
making things come alive in the here-and-now is, I think, the most important skill a group leader can develop.
making things come alive in the here-and-now is, I think, the most important skill a group leader can develop. It's the most challenging aspect of the work, but I think once you're able to do that, I think you really are able to move things to a very effective level in which, I think, people really make meaningful change.
VY: You're describing one of the core skills of group therapists—according to this model, at least—which is how to bring the group into what's called the here-and-now. Now, that's a term that's been bandied around a lot from Fritz Perls onwards. But in this model of group therapy, it has a very specific meaning.
ML: Yes, it does. What is meant by that is moving away from people telling their stories into talking about the experience of telling their stories—getting the group to reflect on itself, and the members' experience with one another.

So, for example, instead of you and I doing this interview in this way—you asking questions, me making comments, you making comments, me responding—a here-and-now approach would be, "What do you really think about my answers? How am relating to you?"

In a chapter I recently wrote I used the example of walking down the street and asking someone for directions. That's a simple transaction at the level of content. But if we were working at that at the level of a here-and-now, what we'd be looking at is the following:How do I feel asking for directions? Am I concerned that my wife, kids, girlfriend will have a negative reaction to me for needing to ask for directions? When I ask somebody for directions, of all the people passing by, what am I using to determine who I will ask? What is it about their demeanor, about how they carry themselves that leads me to ask them the question?
VY: So if you take that lens of looking at group interactions, you're thinking of how people engage in the group. Do they monopolize? Are they quiet? Are they assertive? Who are they drawn to? Who are they distant from, or afraid of?
ML: Exactly. What is the meaning of their behavior? What is driving them? And when I talked earlier about the roadmap, I believe that a group therapist needs to have a very good sense of each person's roadmap in the group. I aspire to operate in this way:that,
in a moment-to-moment fashion, I'm thinking that whatever is happening in the group is either part of the solution or part of the problem. It is either creating opportunities for growth or it is reinforcing pathological behavior.
in a moment-to-moment fashion, I'm thinking that whatever is happening in the group is either part of the solution or part of the problem. It is either creating opportunities for growth or it is reinforcing pathological behavior.
VY: Can you give an example of that?
ML: A woman came into a group, and the important elements of her story were that when she was a youngster, her older sister was diagnosed with leukemia. And the family was concerned, understandably, that this daughter would die. So, they threw all of their resources into caring for this daughter.

My patient grew up with the sense that no one had interest in her; no one was invested in her; that her job was just to make things better for others, and not to ask for anything for herself.

So she comes into treatment with a history of disappointing relationships; failure to advance at work; chronic depression and self-harm. And at the heart of it is her belief that she is to be seen and not heard. In the group, that becomes the important focus of her work.
VY: How is that visible, then, in the here-and-now of the group interactions?
ML: Because she's always helpful to other people. She rarely asks for time for herself. When somebody is crying, she is crying. When somebody is laughing, she is laughing. So she becomes like a Greek chorus rather than a person there in her own right, with her own entitlement.
VY: Now, I imagine that this is a likeable trait in some way, at least initially. People like someone who's attentive to them.
ML: There's a lot of positive reinforcement for her. But ultimately, you have to ask the question, "What is it like for you to be in this group, always giving support and not asking for much back? How do you think others in the group feel about you doing this? What's it like for you coming to the group knowing that that's what's going to happen? What would it be like for you to actually ask for some time? Compare and contrast meetings where you've asked for things from us, and how you felt in the evening afterwards with those meetings where you come and just look after others."
VY: So all of those are ways of getting her to focus on process—her experience of being in the group.
ML: That's correct.
VY: And you do this with other people to give her feedback. Although they may like her attentiveness at first, I imagine they grow tired of it. They don't feel like they ever get to know her.
ML: Exactly. And ultimately, it begins to feel inauthentic.

Another incident occurred recently in a group—a man who had been badly sexually abused as a child came into a meeting feeling very annoyed, angry at how upbeat everyone was about the idea that the group leader presented. This was an early-stage meeting of a group that I supervised. The group leaders proposed that one task of the work in the group therapy was to emancipate themselves from the past. And everyone had been excited about that. But this man was then plagued that whole week with a resurgence of flashbacks and re-experiencing phenomena of the sexual abuse.

He came into the meeting saying, "I have to tell you how angry I am at you that you think it's so easy to escape from the past. I've been reliving my past every day for the last 30 years."

First, that was important because that was the opening for him to talk about the sexual abuse. It was also important because what he went on to say was that he was terrified that expressing his disagreement with us, disagreement with those in the group, would lead to attack. That was his experience, always. Whenever he protested the abuse, it resulted in more abuse.

So that was the first part. And this leads us to the next issue, which is the corrective emotional experience. Once you bring people into the social microcosm—once you illuminate their interpersonal processes, once people begin to push against their roadmap—it's important then to reinforce that, and create an experience that this confirms their pathogenic beliefs, by virtue of insight and a relational experience.

Though with this man, we dived into what was it like for him coming to the group today, knowing that he was going to tell us he was angry with the way the meeting had gone the week before? Who did he think was going to be supportive? Who did he think might be challenging? What does he feel about the job that he's done in protesting his opinion in the meeting today? And so on and so forth.
VY: These are, again, all process-oriented questions.
ML: All process-oriented questions.
VY: And this is done by the leader.
ML: It's done by the leader, and ultimately, as the group matures, it's done also by members of the group.
VY: So you're shaping the group to start doing that work on their own.
ML: That is correct. The mature groups are able to do that on their own.
VY: And the corrective emotional experience you referred to is what? How does this help him?
ML: It helps by virtue of reinforcing the risk-taking, helping him to actually see that although making a protest in his youth led to a crushing attack, the group welcomes it now, and we do not want to silence him or marginalize his experience; we're very interested in the meaning of things for him. And that taking this risk, in fact, makes him better known and closer to us, rather than the opposite—which is his fear that it's going to lead to further abuse.

Training Group Therapists

VY: Let's back up a sec. You've been training group therapists for how many years now?
ML: Thirty years.
VY: And I think you probably run, at the University of Toronto, perhaps the largest group therapy training program anywhere in the world?
ML: I don't know about that. I'd be reluctant to say that because I can't measure it against others, but we have the largest psychiatric residency program in North America, the second-largest in the world. We train about 25 to 30 residents in each of five years of training.
VY: And in your program, how many groups are going on at any one point in time?
ML: I think residents are doing groups of different sorts all over. It would be hard for me to estimate, but I would probably say residents are involved with maybe 30 groups a week.
VY: Let's start with the skill of helping groups get into the here-and-now and talk about their experiences in the group with other members and their feelings about each other. This is a challenging skill to learn—both for beginning therapists and even experienced therapists who aren't group therapists.
ML: It sure is, yeah.
VY: What does it look like actually getting the group to work that way? You've given a lot of examples of the types of questions you ask, but how does that happen, and what's hardest thing for group therapists to learn in terms of doing that?
ML: I think that it's difficult work. And one of the projects that I worked on in the last several years—through AGPA [American Group Psychotherapy Association]—was the creation of a document of clinical practice guidelines for the practice of group psychotherapy. What we've tried to compile in that are all of the elements that I think go into proper running of groups, and hence, proper training of group leaders.

To run effective groups, you have to plan for them wisely, and you have to have support—of the system, of the administration. You have to be aware of how to use the therapeutic factors in group therapy—the importance of cohesion, and the principles that help to achieve and sustain cohesion. You need to be able to select wisely and prepare people properly. You need to be aware of the developmental stages that groups go through. You need to work well with group process. And you need to know how to use yourself effectively as a group therapist, and be mindful of the ethical demands of doing the work.
VY: I just read through this document and it's quite comprehensive. And it does address initially a lot of the institutional challenges of getting groups going—administrative challenges. Just getting enough referrals, if you're in a private practice setting, to start a group—that's a real challenge. What are some of the key considerations and challenges to actually forming groups?
ML: People's resistance to group therapy.
VY: Both patients and systems?
ML: Yeah. I think that there's a general undervaluing of the effectiveness of group therapy. And group therapists suffer because their work is efficient; and people assume if it's efficient and economical, then it's going to be of lesser quality.

The research shows pretty convincingly that for most people, group therapy and individual therapy are equivalent, in terms of their effectiveness.
The research shows pretty convincingly that for most people, group therapy and individual therapy are equivalent, in terms of their effectiveness.
VY: And in terms of that, patients think, well, if there are eight people in the group or nine people in the group, I'm only going to get to talk an eighth of the time, so I can't possibly get as much out of it as if I had the undivided time of the therapist.
ML: Right. They don't have an appreciation yet—and that's where preparation comes in—about how the group works, and how the synergies in the group can make that 90 minutes relevant. Each minute can be relevant to each person.

Also, many of the people who really need group therapy don't have positive experiences in their social groups. They haven't been the most popular kid in high school. They've often felt, earlier in their life, that relationships were hard; or, because of depression, relationships have become hard. So the group is daunting for them.

Take a look at how groups are portrayed in the media and TV and movies. There's a lot of the theme that we throw people out of groups. All the reality shows have to do with people getting extruded. It really feeds into people's apprehension about being the weakest link, or being the first one thrown off the island.
VY: So those are patients' fears. Then there are challenges of getting patients referred your way. Now, if you're working in an institution or a setting where there are lots of patients, it's easier. But if you're in private practice, if you're just relying on your own referrals—unless you have an extremely healthy practice—it's quite challenging to get enough suitable people to get a group going.
ML: For sure. So you weigh it. You think, "Well, I can see these people individually and get paid for each of them by the hour rather than put them together into a group." Groups are not necessarily more lucrative for practitioners in private practice. There's great interest in their applicability in institutional settings, where there's a high volume of patient flow. But it's challenging to get started.
VY: So what advice would you have for a therapist who is, say, in private practice and really excited about doing groups, but doesn't know how to get them off the ground?
ML: I would say get as connected as possible with other providers who will see you as an ally and a resource—whether it's family physicians, primary care providers, or other mental health professionals. And think of a group that has something useful, both as a stand-alone, and also as something to be applied conjointly with other interventions. But you have to be deeply connected.

Something else that I tell all of my trainees is, whenever somebody asks you to see somebody, whenever you have a consultation, make sure you send a note back to the referring professional. Those things really cement the relationship, and increase the likelihood of that person remembering to send people your way.
VY: I've always done one or two groups in my private practice, and always with a co-leader, for a couple of reasons. I enjoy the process of co-leading. So much of our work as therapists is solo, it's been a richly rewarding experience to be able to share and learn from another therapist. But also, just logistically, if we're both drawing on our own referrals, it's been a lot easier to maintain the group over the years.
ML: That makes great sense.
VY: Let me just add one more point. As you well know, in major metropolitan areas, there's a lot of competition among therapists. I've found that doing group therapy is one way to distinguish yourself, since not that many therapists in private practice are offering that.
ML: I think that's a great point. At the University of Toronto, at my hospital, we get a real flow of referrals, because people recognize this is the place where people will be seen and get a good group therapy experience. In our hospital, I typically get 10 or 12 referrals a month for group therapy. So we're able to start each year probably five or six time-limited groups, with eight or nine or ten people in them.
VY: I would guess if you're doing that many groups, you have some different types of groups, or groups that are for people who are at different levels of functioning, so you're able to assess people and place them into appropriate groups.
ML: Right, we do about five or six groups a year, time-limited, interpersonal group therapy. In addition, we run groups for trauma, groups in our day hospital program, groups in the inpatient setting, groups in our geriatric program, women with post-partum depression in our perinatal mental health program. We have a whole range of groups.

And one of the things about groups is that they're very malleable, that you can change your focus and emphasize homogeneous concerns. So I've done lots of groups with seniors with depression; with medically ill patients, women with metastatic breast cancer. We just published an article about using interpersonal group therapy to help people with alcohol abuse to maintain sobriety, and we showed that by dealing with these psychological interpersonal vulnerabilities effectively, we're able to reduce heavy drinking and substance abuse.
VY: So even though many of these are what you called homogeneous groups—in that they revolve around a topic, a symptom, a life challenge—you still put a heavy focus on interpersonal here-and-now relations in the group.
ML: That's right, absolutely.

Group Selection and Preparation

VY: Can you say a little about the selection and preparation of group members, because that's so important to developing healthy, sustainable groups?
ML: I think a shorthand answer is to funnel everything that you do through the therapeutic alliance. The therapeutic alliance is the best predictor of outcomes, across all kinds of psychiatric treatment and psychotherapy. What we look for is the degree of agreement, between the treater and the patient, about the goals of treatment, the tasks of treatment, and the nature of the relationship.
VY: You're doing that in the first assessment meeting?
ML: Yes, that's something we're doing right from the start. If their goals are not in sync with our goals, then the group's not going to be an effective experience for them. They may need to be in another kind of group.

Now, what do people need to be able to do to engage in the tasks of treatment? They need to be able to come reliably. They need to be able to sit in the group. They need to be able to speak. We're talking about having the logistical, intellectual, and psychological ability to actually make use of what the group provides.

So I find it very helpful to be able to ask and answer the question, "Do we have convergence on the goals of treatment? Do you have convergence about the tasks of treatment?" Then I talk a little bit about what they can expect from me in terms of the therapeutic relationship and from the relationships in the group.
VY: But if someone is coming to you or your clinic because they're depressed, for example, and you're suggesting, "Gee, rather than go into individual therapy, I think you might really benefit from a group," you need to explain to them how a group works, and how it might be helpful.
ML: Exactly.
VY: What are some ways you do that?
ML: Well, I think virtually everything that we've talked about in the interview so far, Victor, I would share with them:the research that shows it's an effective modality of treatment; how it would work; how I think it would work for them specifically, with regard to understanding how their difficulties—with passivity, assertiveness, anger, self-esteem—contribute interpersonally to the difficulties that they're having in their life at large; and that the lens that we're going to look through is what's happening at the level of interpersonal relationships.

Then I'll talk about the microcosm of the here-and-now, interpersonal learning, the corrective emotional experience.
VY: So you really lay it out for them—how the group works, how it might benefit them.
ML: Absolutely. There is an appendix in the Fifth Edition, of a preparation document that therapists can give to their clients. You can personalize it, but it really covers and nuts and bolts of what we feel needs to be communicated to people.

there's robust research evidence that well-prepared clients do much better in group therapy. They stay longer, they work better, they understand the tasks, they're more popular group members and much less likely to drop out.
there's robust research evidence that well-prepared clients do much better in group therapy. They stay longer, they work better, they understand the tasks, they're more popular group members and much less likely to drop out.
VY: Right. And dropouts can be a big problem in groups—not only for the clients who drop out, but it can be demoralizing, or threaten the very existence of the group.
ML: Yeah. It's very hard, in particular when people are beginning to do group therapy, to have dropouts. The residents that I supervise are heartened by two comments. One is that dropouts are inevitable, and that no one in the literature, even in the most experienced hands, is able to eliminate dropouts, and the range is anywhere from 10 to 40 percent.

The other point is that if you never have any dropouts, then it means you're setting the bar for entry into your group too high, and you're like a surgeon who only operates on people without any risk factors. And it means that you're missing the opportunity to be helpful to a lot of people who would otherwise benefit from treatment.
VY: But if the bar is too low, and you let a lot of people into the group who don't stay very long, it can be disruptive and demoralizing to the group.
ML: No question.
VY: You talked about preparation and the research showing how important that is. One thing I've heard about in some institutional settings people are doing intake over the phone and are sent to a group without much screening or meeting with the therapist. That seems like it can cause a lot of problems.
ML: I have to say, I understand the pressures that some organizations are under; but to me, it's being penny-wise and pound-foolish. If you want preparation to really take hold, it should be provided by the person who is actually going to be doing the group. Part of the rationale for preparation is to begin to establish the therapeutic relationship, and you want to screen people in a more meaningful fashion. So I think if you cut the front-end short, you end up paying at the back-end.

Co-Leading Groups

VY: Another problem that I've heard about is interns in agencies being matched up with a staff member, a more experienced therapist—which is great, in theory. I mean, most of the time in our training we're thrown in the room alone with the client, and we don't have the chance to learn directly from working with experienced practitioners—which is how professionals generally are trained, whether in fields of law or surgery or accounting.

But it often seems that interns are thrown into co-leading a group, and there isn’t sufficient time allotted to meet with the senior therapist for several sessions prior to starting a group to make sure they’re on the same wavelength. Or they may not have time to meet after the group to debrief. And there can be tensions between the group leaders that aren’t worked through.
ML: All those things happen, but I think they are by and large avoidable if people, number one, are working in good faith, and if there's a commitment on the part of the more experienced group leader to promote the growth and development of the trainee. And the only way to enact that good faith is to actually have time to meet before the group and after the group. If you're not doing that, then you're not giving yourself a chance to be successful.
VY: In your training program, is there a lot of co-leading that goes on? Do you pair residents with staff or with each other?
ML: Mostly with each other. But for 30 years, I've led at least one or two groups a year with the residents. I often tell them that my first real experience leading a group involved, I think, the greatest gradient imaginable between my experience level and the experience level of the person I was co-leading with, which, of course, was your dad.

When I began to do groups with your father, at the beginning of my fellowship at Stanford, I had had very little experience in groups. And I remember vividly—and I tell this story often—that one of the groups I co-led with your dad that he brought me into was a group he was leading for mental health professionals, all of whom had done group work. Some of them were even teaching group therapy.

I remember one group session when somebody came into the group with The Theory and Practice of Group Psychotherapy that they were using in a class that they were teaching. And I felt really de-skilled, small and marginalized, which was a very uncomfortable feeling.

But I talked about it with your dad, and he responded, in essence, "This group is too dependent on me, and that's why they're not making any room for you. It's not good for you, it's not good for them, it's not good for me. So look for an opportunity."

Ultimately, after several weeks, I identified that I felt no one in the group was paying any attention to what I had to say. And this goes to show you that there is an unconscious—I meant to say that people were just waiting and deferring for this "wise old therapist," in reference to Irv.

But I didn't say wise, I said wizened, and I didn't realize it! Irv, afterwards, when we rehashed it, had a great laugh
But I didn't say wise, I said wizened, and I didn't realize it! Irv, afterwards, when we rehashed it, had a great laugh and teased me about the Oedipal strivings that were evident in that slip of the tongue.

I think in co-therapy you have to anticipate competition, rivalry, tension. But hopefully, as I say, if people are working in good faith, these don't become insurmountable problems, but, in fact, become learning points.

I often tell residents, if you are a passive co-leader with a more active co-leader, what message does that give the quiet members of the group? It models for them that it's okay to take a backseat. And that often has a powerful impact.

I think most people are also heartened to hear that I was able to address the gradient of my limited experience working with your father at Stanford in 1980. If I can do that, they can do what they have to do here.
VY: I hadn't heard that story before from you, but we share that experience, because I led a group with him very early in my training, and certainly had similar experiences—that I knew very little and felt I had little to offer. It was a challenge for me to speak up and feel that I did have something to contribute.
ML: Absolutely. It's part of the consequence of the very large shadow that your dad has cast.
VY: Indeed.

You’ve trained many, many therapists over the years, group therapists. What are some of the things that are most challenging for them to learn about being effective group therapists?
ML: I would say the most difficult thing has to do with learning how to use oneself effectively as a therapist, and how to use language effectively—how to be able to communicate meaningfully with our patients; the risks that we need to take sometimes; how to be appropriately transparent, including the limits of transparency.
VY: What kind of risks?
ML: The risk of giving feedback to a patient. Oftentimes, especially young therapists are very reluctant to do that, because they feel that it's going to fudge the boundaries.
VY: Do you think there are still some vestiges of the blank slate?
ML: Still some—and now with the added overlay of, "If I'm too personally present in the group, is that a slippery slope that's going to lead to some boundary issues later?" Still dealing with the aftermath of the '90s and all the focus on boundary crossings and boundary violations.
VY: What's your take on that?
ML: I think that it's impossible for a person to be in a room with another person and not to disclose. So I would rather be proactive and mindful about it rather than think it's not happening.
VY: Rather than think that the way to avoid the possibility of some kind of inappropriate behavior is just to set a hard-and-fast rule that we're neutral and we're impartial bystanders.
ML: Exactly—to be stilted, distanced. I think fundamentally group therapy is a human experience, and we have to be humans in it.

I think that probably the best line that a patient ever articulated in a group—this was a senior person who was close to leaving the group, who was welcoming somebody new into the group—she said, "You know, you're beginning now. Likely, you're going to be skeptical about this, the way I was skeptical for the longest time. My first impression was that the group was a very natural place for unnatural things to happen. And then," she said, "with a little bit more time, I realized that, in fact, the group is an unnatural place—it's constructed for this purpose—but that what happens here is very natural."

A real endorsement of the meaning and the value of the relatedness.
VY: Yeah, because it is a contrived situation. People are paying money to be there. And yet the nature of the relationships, and the events that occur in the group, become extremely meaningful to people in a successful group.
ML: Incredibly so.
I've had many, many patients say to me that the group is what anchors them, and that they carry the group with them. They think about the group all the time.
I've had many, many patients say to me that the group is what anchors them, and that they carry the group with them. They think about the group all the time.

In fact, one woman in a group that I run commented that she holds onto images of people in the group during the week to help her deal with adversity. And when that woman graduated from the group—a very successful ending; she was leaving to get married, having previously—a woman in her thirties—having never had any sexual contact—one of the other members of the group, who is an accomplished artist, gave her, as a going-away gift, these beautifully crafted popsicle-stick figures of each of the group members, made out of material and wood and painted. Just a beautiful embodiment of the internalization of the members of the group. Touching.

The Best Kind of Work to Do

VY: And, needless to say, as this has been the focus of your professional life, it can be a deeply rewarding experience for a group therapist.
ML: Absolutely. I think it's the best kind of work to do.
VY: How has it been rewarding for you?
I think that we grow as our patients grow. You can't do this work and be static.
I think that we grow as our patients grow. You can't do this work and be static. All of the things that I've learned about people, about the world, have shaped me in very constructive fashions. Even dealing with people who are facing death—our metastatic breast cancer research—has made me more existentially aware; the meaning of their experience, I think, has added meaning to my experience.

Your father has written extensively, of course, about existential approaches to psychotherapy, and I think there is enormous value in that. Life is short. Make use of it. Author your life in a way that is meaningful to you; you're personally responsible for authorship.

I often tell the story of the woman that I first encountered in the metastatic breast cancer group who subsequently graduated from that group. She is one of the long-term survivors from that group. Most of those women died within a year or two. This woman was diagnosed with metastatic breast cancer when she was 26, if you can believe it, and she's still alive and thriving twenty years later.

I saw her September 12, 2001, right after 9/11—and she comments to me what a terrible tragedy the World Trade Center attacks were. But it crystallized for her that if she had been in the World Trade Center on 9/11 and had died, she took heart from the fact that she would not have had one moment's regret of how she lived her life on September 10.

I think that's something that I aspire to, and I think, if we're able to help our patients aspire to that, then we're going to help them a great deal.
VY: Well, I think that's an inspiring and encouraging note to end on. I want to thank you so much for taking the time to share your wisdom and passion about group therapy.
ML: If we speak for a moment, too, Victor, about our here-and now, it's a remarkable sequence. I've benefited so much from my relationship with your father, and to be able to talk about that work with you in your career, in this way, feels like another good loop.
VY: It feels absolutely that way for me. And that's an example I can't help noticing from a process lens:when you shifted the conversation away from the content—group therapy—to making it a personal connection between you and me, I found myself moved in an emotional way that I hadn't previously in this conversation.
ML: I feel that, Victor, and I'm glad that it touched you in the same way. I would have not wanted our conversation to end without making the comment.
VY: Thank you very much.

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Molyn Lesczc Molyn Leszcz, MD, FRCPC, CGP, DFAGPA. Dr. Molyn Leszcz is Professor, Department of Psychiatry, University of Toronto. He served as President of the American Group Psychotherapy Association, from 2020-2022. Dr Leszcz also served as Psychiatrist-in-Chief at Sinai Health System, 2006-2017, Vice Chair, Clinical for the Department of Psychiatry, University of Toronto, 2010-2017, and Chair (Interim) the Department of Psychiatry, University of Toronto, 2014-15. Dr. Leszcz’s academic and clinical work has focused on improving integration in psychiatric care and broadening the application of the psychotherapies within psychiatry. Dr. Leszcz has worked extensively in the areas of physician wellness and leadership, along with the effects of pandemic stress on health care providers. He co-authored with Irvin Yalom, the 5th and 6th (2020) editions of the Theory and Practice of Group Psychotherapy. A co-authored book in the Psychotherapy Essentials to Go series, Achieving Psychotherapy Effectiveness, was published in 2015. Dr. Leszcz was awarded the Anne Alonso Award for Outstanding Contributions to Psychodynamic Group Therapy and also was awarded Distinguished Fellowship in the American Group Psychotherapy Association. Dr. Leszcz has been the recipient of a number of education and teaching awards at the University of Toronto.
Victor Yalom Victor Yalom, PhD is the founder and resident cartoonist of He maintained a busy private practice in San Francisco for over 25 years, but now sees only a few clients, devoting the bulk of his time to creating new training videos for He has produced over 100 videos, conducted workshops in existential-humanistic and group therapy in the US, Mexico, and China, and currently leads consultation groups for therapists.  More info on Victor and his artwork and sculpture at

CE credits: 2

Learning Objectives:

  • List the core principles and assumptions of the interpersonal model of group psychotherapy
  • Explain how to make process-oriented interventions
  • Create healthy, sustainable therapy groups that minimize dropout

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here