1. Yalom’s Therapeutic FactorsBy
Patti Higgins

2. Yalom’s Therapeutic Factors
Yalom (1995) defined therapeutic factors as "the actual mechanisms of effecting change in the patient" (p. xi).
Yalom identified 11 factors that influence the processes of change and recovery among group therapy clients.

3. 11 Therapeutic Factors
Universality - feeling of having problems similar to others, not alone
Altruism - helping and supporting others
Instillation of hope - encouragement that recovery is possible
Guidance - nurturing support & assistance
Imparting information - teaching about problem and recovery
Developing social skills - learning new ways to talk about feelings, observations and concerns
Interpersonal learning - finding out about themselves & others from the group
Imparting of Information
Imparting information refers to instruction, sharing knowledge and teaching patients. Didactic instruction adds structure to the group. Often, therapists explain the nature of mental illness, the process of recovery and relevant information (Corey, 2000; Yalom, 1995). This imparting of information resembles psychoeducational techniques to empower patients through education. With shared knowledge, the therapist and patient work together as partners in the treatment process.
Altruism
Altruism involves helping other people. Patients often find helping others refreshing and self-esteem-boosting (Corey, 2000). They can renew their life-purposes Development of and find meaning in being of service to fellows. Patients who might have considered themselves burdens may now view themselves as helpful, productive members of society (Corey, 2000; Forsythe, 1999; Yalom, 1995).
Socializing Techniques
In group therapy, a patient learns about others’ impressions of his or her current social skills (Corey, 2000; Earley, 1999; Forsythe, 1999;Yalom, 1995). Members may discover they have been unconsciously sabotaging relationships with their ineffective social habits. By learning new ways to talk about feelings, observations and concerns, patients can gain assertive, yet empathic, communication skills.
Interpersonal Learning
Interpersonal learning involves patients’ finding out about themselves and others from their group experiences (Corey, 2000; Yalom, 1995). They learn that what they do or say might affect other people. Similarly, they become aware of why and how they might have developed particular behavior patterns. With support and feedback, they learn to improve their behavior and subsequently, their interpersonal relationships (Corey, 2000; Yalom, 1995).

4. 11 Therapeutic Factors
Cohesion - feeling of belonging to the group, valuing the group
Catharsis – release of emotional tension
Existential factors – life & death are realities
Imitative behavior – modeling another’s manners & recovery skills
Corrective recapitulation of family of origin issues – identifying & changing the dysfunctional patterns or roles one played in primary family
Cohesiveness "refers to the condition of members feeling warmth and comfort in the group, feeling they belong, valuing the group and feeling, in turn, that they are valued and unconditionally accepted and supported by the other members" (Yalom, 1995, p. 48). Patients that come to therapy have often experienced feelings of isolation before joining the group. Initially, the group may represent their only interpersonal contacts. After only a few sessions, patients may derive a sense of feeling more at home in the group than anywhere else.
Catharsis
Catharsis refers to the release of emotional tensions (Forsythe, 1999; Yalom, 1995). Patients gain relief or catharsis by expressing feelings verbally and nonverbally. Catharsis has also been described as a feeling of ventilation, liberation and healing. Patients can experience catharsis by expressing their thoughts, fears, feelings through such exercises as crying, yelling, kicking pillows or writing.
Existential Factors
Existential factors include recognizing that even with guidance and support, everyone is ultimately solely responsible for the way he or she lives (Corey, 2000; Earley, 1999; Forsythe, 1999;Yalom, 1995). Additionally, regardless of close relationships, people still face life alone. Existential factors assume that life can be unfair and unjust; nobody escapes pain in life; nobody escapes death. Issues of life and death are inevitable, therefore people should cherish life by living honestly and letting go of trivialities. Existential psychotherapy enhances patients’ self-knowledge and frees them to become the authors of their own lives (Corey, 2000; Earley, 1999; Forsythe, 1999;Yalom, 1995).
Imitative Behavior
This therapeutic factor stems from Bandura’s (1977) social learning theory (Forsythe, 1999). Modeling involves demonstrating particular behaviors while the group members observe, then try to imitate them (Bandura, 1977). Therapists should model effective social skills necessary for interpersonal communication. As members progress throughout therapy, they will begin to pick up phrases and behaviors that seem to work for others. In the safety of the group, patients can practice these new social skills without fear of rejection or ridicule.
Corrective Recapitulation of the Primary Family Group
“Therapy group reincarnates the primary family” (Yalom, 1995, p. 87). Patients’ will naturally assume roles that resemble their previous roles in their families of origin. Their behaviors, attitudes, communication styles and interactions reflect what they learned as children in their families (Corey, 2000; Earley, 1999; Forsythe, 1999;Yalom, 1995). Their dysfunctional defense mechanisms, such as taking charge, rebelling, keeping quiet, being fearful, or distrusting others will reappear in the group. Through therapy, these patterns are recognized and corrected.

5. Measurement of Therapeutic Factors
Assessment of factors
Yalom Q-sort assesses patients’ perceptions of therapeutic factors and consists of 60 statements representing 12 categories of therapeutic factors. A ranking of 1 to 60 is produced.
Bloch, Reibstein, Crouch, Holroyd and Themen's (1979) assessment uses independent raters to judge presence of therapeutic factors.
Therapeutic Factors Inventory (TFI) - empirically derived comprehensive assessment of the presence or absence of the 11 therapeutic factors in a group (Lese & MacNair-Semands, 1997)
Measurement of Therapeutic Factors
The Yalom Q-sort assesses patients’ perceptions of therapeutic factors. The Yalom Q-sort consists of 60 statements representing 12 categories of therapeutic factors (McLeod & Ryan, 1993; Yalom, 1995). These include Altruism, Group Cohesiveness, Universality, Interpersonal Learning Input, Interpersonal Learning Output, Guidance, Catharsis, Identification, Family Re-enactment, Self-Understanding, Instillation of Hope, and Existential Awareness (McLeod & Ryan, 1993; Yalom, 1995). The Q-sort takes approximately one hour to administer. Research participants are given cards with the statements printed on them that reflect the therapeutic factors, and are asked to place these in piles under seven headings, ranging from `most helpful to me in the group' to `least helpful to me in the group'. Then, participants rank order the cards from `most helpful' to `least helpful'. The Q-sort produces a ranking of 1 to 60 for each item for each member. The rank of 1 indicates the most helpful item, and 60 the least helpful one (McLeod & Ryan, 1993; Yalom, 1995). Then, if research with several participants, is being conducted, rankings for each item are combined. Then, the rankings for items within particular categories (e.g. cohesiveness or universality) are added together, to obtain a figure for the overall perceived helpfulness of that factor within the group (McLeod & Ryan, 1993; Yalom, 1995).
Another assessment method, the Therapeutic Factors Inventory (TFI), has 11 scales based on Yalom’s therapeutic factors. Lese & MacNair-Semands (2000) developed this empirical framework to measure patients’ perceptions of Yalom's (1995) 11 therapeutic factors in group therapy. Reliability testing indicated each scale of the instrument demonstrated high internal consistency. However, the one scale, Corrective Reenactment of the Primary Family Group scale, did not obtain acceptable test-retest reliability. The researchers recommend further testing.
MacNair-Semands (2000) notes:
Currently, the Therapeutic Factors Inventory (TFI) is the only empirically derived and comprehensive assessment of the presence or absence of the 11 therapeutic factors in a particular therapy group (Lese & MacNair-Semands, 1997, in press; MacNair-Semands, 1997; MacNair-Semands & Lese, 2000), and this measure is in its youth with regard to validation. (MacNair-Semands, 2000, p. 254)
A third assessment measure involves independent raters. Holmes and Kivlighan (2000) described Bloch, Reibstein, Crouch, Holroyd and Themen's (1979) system as a widely used, empirically based system for categorizing or classifying therapeutic factors. In Bloch et al.’s (1979) system independent raters assign patients’ descriptions of important session events to categories of therapeutic factors. These specific factors include catharsis, self-disclosure, learning from interpersonal actions, universality, acceptance, altruism, guidance, self-understanding, vicarious learning and instillation of hope. Although these factors vary slightly, they strongly resemble Yalom’s 11 factors and can be used to assess group members’ perceptions (Holmes & Kivlighan, 2000).

6. Navajo sweat lodge study
Colmant and Merta (1999) explored the Navajo sweat lodge ceremony as a culturally relevant and therapeutic approach to group therapy. They compared the sweat lodge ceremony used at a residential treatment center for Navajo males aged 6-15 years old with disruptive behavior disorders, to modern group work with Yalom’s therapeutic factors.
For example, Colmant and Merta (1999) explored the Navajo sweat lodge ceremony as a culturally relevant and therapeutic approach to group therapy. They compared the sweat lodge ceremony used at a residential treatment center for Navajo males aged 6-15 years old with disruptive behavior disorders, to modern group work with Yalom’s therapeutic factors. They explained that the various ceremonial rituals encompassed Yalom's 11 therapeutic factors. Patients and therapists experienced all factors throughout various parts of the ceremony. The researchers consider use of the ceremony with Native Americans and non-Native Americans a viable treatment option and recommend future research.

7. Differences among factors’ values
Older women in an outpatient therapy group ranked existential awareness as the most important therapeutic factor (McLeod & Ryan, 1993).
Morgan & Ferrell (1999) found therapists' perceived interpersonal learning, universality, & imparting info highest for group of incarcerated males.
Schwartz and Waldo (1999) found imparting of information and development of socializing techniques most valuable in educational groups for batterers.
Campbell & Page (1993) found recovering drug addicts ranked highest: information dissemination, corrective recapitulation of the primary family, development of socializing techniques, imitative behavior, interpersonal learning, group cohesiveness, and catharsis.
Mawson & Kahn (1993) reported women in career counseling group rated cognitive and affective components as most valuable.
Tomasulo, Keller & Pfadt (1991) found psycheducational groups therapeutic.
Kivlighan & Goldfine (1991) found guidance increased across the stages of group, universality and hope decreased, and catharsis increased in beginning.
Group members may rank therapeutic factors differently based on their characteristics, culture, age and backgrounds. For example, a group of eight older women in an outpatient therapy group ranked existential awareness as the most important therapeutic factor (McLeod & Ryan, 1993). “Existential Awareness came out clearly as the single most influential factor, with all five Existential items appearing in the list of ten most chosen items” (McLeod & Ryan, 1993, p. 64).
In another study, Morgan & Ferrell (1999) evaluated group therapists' perceptions of therapeutic factors in psychotherapy groups for incarcerated male inmates. More than 100 therapists completed surveys to assess their perceptions about therapeutic factors as group goals, time spent processing specific factors and level of group progress. The therapists ranked interpersonal learning, universality, and imparting information as most valuable.
Some particularly therapeutic factors for one group of recovering drug-addicts included information dissemination, corrective recapitulation of the primary family, development of socializing techniques, imitative behavior, interpersonal learning, group cohesiveness and catharsis (Campbell & Page, 1993).
Schwartz and Waldo (1999) examined the perceived importance of therapeutic factors in educational groups for batterers. The study included 38 men (aged years) attending classes for spousal abuse. Results from therapeutic factor questionnaires indicated that the participants valued imparting of information and development of socializing techniques the most.
Women who attended process groups in a career planning intervention were asked to rank therapeutic factors (Mawson & Kahn, 1993). The women described cognitive and affective components of the career counseling groups as most valuable.
Most group processes can be analyzed according to existence of therapeutic factors (Tomasulo, Keller & Pfadt, 1991). Even psychoeducational groups can identify various factors that make the experience most beneficial. For example, interactive group therapy can be modified to teach anger management; AIDS awareness training; relationship counseling; sexual abuse avoidance training; mental health counseling; vocational readiness; behavior management; travel training; independent living.
Kivlighan & Goldfine (1991) examined Yalom's (1985) hypotheses about interpersonal styles, stages of group development and endorsement of therapeutic factors. In a 1991 research study, they found that “universality and hope decreased and catharsis increased over MacKenzie's (1983) initial stages of group development” (p. 150). Furthermore, guidance increased across the stages.

8. Yalom’s adages:
Therapy group is a social microcosm and a reenactment of the primary family.
Therapists should listen to their patients.
Patients should listen to and learn from one another.
Yalom’s (1995) adages include: group is a social microcosm and a reenactment of the primary family, therapists should listen to their patients, and patients should listen to and learn from one another.