This article reviews studies of the group curathe process that have employed Yalom’s

description of group curative factors. Similarities and differences in the findings of the
studies are discussed and future directions for research in this area are indicated.

CURATIVE FACTORS IN
GROUP THERAPY
A Review of the Recent Literature

TIMOTHY BUTLER
Iowa State University

ADDIE FUHRIMAN
University of Utah

The therapeutic or curative quality of patient-therapist

interaction has long been a focus in psychotherapy research.
More recently, this focus has also been evidenced in group
therapy research which, of necessity, includes not only patient-
therapist but patient-patient and patient-group interaction as
well. The therapist-researcher most associated with the study
of curative factors in group therapy is Irvin Yalom. In1970 he
introduced a 12-factor construct of the curative process in
group psychotherapy (Yalom, 19],0, 1975), His approach is
based on a synthesis of earlier research (Corsini and
Rosenberg, 1955; Dickoff and Lakin, 1963 ; Berzon et at~ 1963)
and his own research and clinical experience. He labeled his 12
curative factor constructs as follows: self-understanding, inter-
personal learning (input), interpersonal learning (output),
universality, instillafion of hope. altruism, recapitulation of
the primary family group, catharsis,,, cohesiveness, identifi-
cation, guidance, and the &dquo;existential&dquo; factor, By 1980, Yalom’s
book based on this framework had become the text most

SMALL ORQUP BEHAVIOR. V~1. 14 Np. 2, May 19$3 131-142

e 1983 Sage Publications, Inc.

131

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 132

frequently used in the graduate school training of group there-

gZ

pists (Dies, 1980). .

In the past decade, a number of researchers have attempted

to study the group therapy experience utilizing ’~alo~’s 12-
factor model. A review of the literature has identified 12 stu-
dies on 13 different therapy and personal growth group sam-
ples. t1&dquo;Yâ1om ~ et al., 1970; Maxmen, 1973; Weiner, 1974;
Uebermanet~~,1973;Rohrbaugh~nd
1975; Sherry and Hurley, 1976;
Long and Cope, 1980; Mower, 1980;
B~lIf 1~75; Schaffer,
and 1-~u~riman,
Butler
Flora-Tostado,
1980;
1981;
Butler and Fuhriman, forthcoming). These studies have a
considerable range in terms of sample size and sophistication
of research design and analysis. While a few of the authors
have attempted questionable generalizations from isolated
studies on small samples, most of them have called for replica-
tion using Yalom’s model to study different group therapy
populations. After a decade of research, it is an appropriate
time to review these studies with the task of identifying consist-
ent findings as well as noting some of the methodological
problems that have limited the utility of this particular
Approach to exploring group therapy process.
7 The intent of most of the studies reviewed here has been to
identify the most salient therapeutic factors from the per-
spective of group members. Most of the studies utilized the
same instrument for surveying group members’ perception of
the most beneficial aspects of their therapy. This instrument
was ~~lon~’s 60-item curative factor questionnaire, whichco=
sists of 5 items for each of the 12 factors. These items were
administered in either a Q sort or, it Likert scale fashion,
arriving at-a total score for each factor, which, in turn, was
used in determining a rank ordering of factor importance.
These ~ items are available in ~alo~’s 1~’~0 book, The Theory
and Practice of Group Psychotherapy, (1910, 1975). Three
studies (Butler and ~~hr~,u, 1980; Lieberman 8t ~.~ 1973;
1973) used different instruments to measure Yalom
factors. These modified instruments typically utilized single
questionnaire or card sort items to represent -each curative
factor.

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 133

I I
T~L~ 1’~ °

Curative
F&dquo;rt V;31 ued Most
Highly by
I

Oupatie~t~Therapy 5~~~~~~~m~,rs
~ronp
Oupati~nt Therapy I~ler~b~r~

Three, general types of groups have been studied using

Yalom’s model: outpatient psychotherapy groups, personal
growth groups, and groups for hospitalized or partially hospi-
talized psychiatric patients. Tables 1, 2, and provide basic
information€or each of these three types ofgr-Qups. Included in
these tables is information on group studies reviewed that were
conducted on a sample of more than one therapy group. Each
table provides the sample size, group setting, and rank order of
the top four factors in each study.
Table 1 indicates that three factors appear consistently at
the top of the list of factors in most of the outpatient group
studies: seM-undcrstaading~ catharsis, and interpersonal
learning(input). A fourth factor, -co-h-4sivems, i~shighly valued
also, but a closer look at the rank ordcrings revealed that it was
ranked somewhat lower than the three factors mentioned
above.

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 134

Outpatients value the interpersonal learning (input) factor

representing the therapeutic construct of receiving &dquo;feedback&dquo;
from other group members; they value hearing, understanding
and learning about their effect on others, and others’responses
to their behavior. Butler and Fuhriman (forthcoming) con-
ducted an item analysis on Yalom’s questionnaire and found
that the item most highly correlated with the total score of all 5
interpersonal learning (input) items was &dquo;The groups teaching
me about the type of impression I make on others. &dquo;The highly
valued self-understanding factor represents the therapeutic
concept of gaining insight into some of the causes of one
behavior. Members value discovering reasons that explain
their feelings and actions. The item (Butler and Fuhriman,
forthcoming) most highly correlated with all of the self
understanding items reads: &dquo;Learning that I react to some
people or situations unrealistically (~vith feelings that somehow
belong to earlier periods in my life).&dquo; The remaining highly
valued catharsis factor describes the therapeutic action of
recognizing and expressing emotions within the group setting.
Members value being able to share their feelings and expe-
rience relief from such sharing. The item from ~alo~n’s ques-
tionnaire (Butler and Fuhriman, forthcoming) most highly
’ correlated with all of the catharsis items reads as follows:
&dquo;Being able to say what was bothering me instead of holding it
in.&dquo; An additional ordering observation is found in Yalom et
al.’s (1970) study, which determined a rank ordering of the 60
items of Yalom’s questionnaire according to the therapeutic
importance attributed to them by 20 &dquo;successful&dquo; group
patients. The three top-ranked items include one each from the
self-understanding, catharsis, and interpersonal learning
(input) categories.
Yalom (1970) had advanced the viewpoint that neither the
experience of emotional catharsis nor cognitive analysis (self-
understanding) alone accounted for consistent therapeutic
gain in a group setting. Rather, it is the act of reflecting on a
poignant emotional experience that combines these two fac-
tors into a potent therapeutic &dquo;event.&dquo; Yalom described the
therapeutic event as being essentially interpersonal in nature;

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 135

that is, both the emotional experience and ~e~~t~ansare t~~-

c-ally evoked and facilitated by interaction with~other group
members. It is the availability-Qf multiple interpersonatpossi-
pilities (versus the MkOr~Ji11Úted two-person a~rangemeMt of
inaividual therapy( whiah provides the unique therapeutif,
potency of the gmup setting. ’.&dquo; r
} r -

Weiner (1974), however thought that Y4oxn’s notion of the

grqi4p,therapeutic process underestimated the importance of
jmem~r in-sight into earlier events that are the primary sources
~ ~ ~urr~n~ adaptive problems or symptoms. He felt that
Yalom’s focus on the importance of &dquo;here and now&dquo; inter-
petsonal,e, xpcricoco within the. grou, p faile-d to give sufficient
credit to~~he &dquo;impact of property timed genetic interpretation
repeated in -sufficient different contexts to be able to be inte-
grated meaningfully by patients&dquo; ~p. 236). _

Weiner was further coneerned that Yalom’s questionnaire

was biased against the importance of genetic insight. This
concern doesnot seem warranted in retrospect. Weiner
thought that the therapeutic, value of interpretations of the
relationship between earlier events and current behavior was
represented in Yalom’s model by one factor, the recapitulation
off the primary family group factors. This factor has received a
consistently low rating in all empirical studies of the factors,
What Weiner apparently did not attend to, however, is the fact
that the self-understanding factor also strongly represents a
more general therapeutic value of becoming aware of the
connection between past events ar relationships
and current
behavior. Three of the five items representing self-under-
standing deal explicitly with the importance of the influence of
past events or relationships on present problems.
The consistently highly valued triad of factors of the outpa-
tient therapy groups contains all of the elements that comprise
Yalom’s model of the group therapeutic mechanism. The pres-
ence of the interpersonal learning (input) factor among the top
three factors provides considerable support for his emphasis
on the importance of the &dquo;here and now&dquo; experience of direct
feedback from other group members. At the same time, the
presence of the self-understanding factor in this top-rated triad

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136

affirms, from the ~at~nt’~ perspective, the therapeutic impor-

tance of gaining cognitive awareness of causes, including his-
torical causes of their behavior. f
Three studies reviewed concerned themselves exclusively
with personal growth groups (Table 2). Two of the three
factors composing the triad of most helpful-factors for out&dquo;...
tient groups show some consistency in these groupsalso.
Catharsis is absent from the top of the list in two of the three
studies. It is difficult to determine if there is any significance t-6
this observation, or whether it is a consequence of the small
number of studies represented. Both Tfalom( 1975) and Sherry
and Hurley (1976) make the point that there ~e strong similar-
ities between the manner in which members of personal growth
groups and outpatient therapy groups view the group helping
process. On the other hand, there may be some distinctive
characteristics of the two group types, such as length of time in
group, that would cause members to value different factors. It
is not possible to support or deny definitively the similarity
viewpoint from the limited number of studies available, but the
evidence appears to be in favor off the similarity between
personal growth and outpatient therapy groups.
Maxmen (1973), in the concluding statement of his paper on
group curative factors as perceived by hospitalized psychiatric
patients, made the following point:

The discrepancy between the factors valued by hospital and

clinical patients would suggest that the theoretical assumptions
and practical techniques utilized by outpatient group therapists
may need modification if they are to be used more effectively
with psychiatric inpatients [p, 4fl8~,

Butler and Fuhriman ( ~9g4) came to the similar conclusion

that patients in partial hospitalization groups were helped by
different experiences than patients in outpatient therapy
groups. They discovered that the cohesiveness factor had sin-
gular importance for day treatment group patients. The cohe-
siveness factor stood alone at the top of the day treatment
group list, with the next 8 factors grouped around the mean of
the 12-factor ranking. Butler and Fuhriman concluded that the
day treatment patients were poorly able to differentiate among
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138

choices 2 through 9, and that the cohesiveness factor stood out

as having salient therapeutic value in the eyes of these patients.
For this reason, only cohesiveness is listed in Table 3 for the
~

Butler and Fuhriman study.

In Maxmen’s (1973) study, instillation of hope received the
highest number of most valued rating and was ranked first.
Cohesiveness was ranked second but received more moderately
helpful ratings than the hope factor. Self-understanding,
catharsis, and interpersonal learning (input) do nof appear in
the top choices in Maxmen’s study. Although catharsis and
insight were nominally third and fourth in the Butler and
Fuhriman study, they were not regarded ~ any more valued
than six of the other factors. This information lends strong
support to two statements: (1) Hospitalized or partially hospi-
talized group therapy patients value the therapeutic process
differently than outpatient group members,; and (2) the expe-
rience of cohesiveness, or belonging to a caring group, appears
to be a vital feature of group therapy for more severely dis-
turbed psychiatric patients, whether this disturbance is of an
acute or chronic nature.
Butler and Fuhriman (forthcoming) found that &dquo;higher-
functioning&dquo; outpatients valued self-understanding, catharsis,
interpersonal learning (input), and interpersonal learning
(output) more highly than did &dquo;lower-functioning&dquo; outpatients.
Although the subjects were not a hospitalized population,
Butler and Fuhriman’s findings are consistent with the idea
that the triad of factors most valued by outpatients decreases
in value for individuals experiencing more incapacitating psy-
chiatric problems.
Rohrbaugh and Bartels (1975) provide a discussion of two
basic weaknesses of measuring group helpfulness with an
instrument such .as Yalom’s questionnaire. The first, as Yalom
acknowledges, is that the 12 factors do not represent
independent dimensions of helpfulness; that is, a &dquo;curative&dquo;
experience is probably a complex interaction of more than one
of the aspects represented by Yalom’s individual factors.
Butler and Fuhriman’s (forthcoming) statistical analysis found
that the factors are indeed highly intercorrelated. Although
curativeness is an interaction of factors, increased independence
of individual factors could be obtained by refinement of spe-

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140

cific items. For example, the item that reads &dquo;revealing embar-
rassing things about myself and still being accepted by the
group&dquo; combines the concept of catharsis as well as cohesion.
The second obvious drawback of the questionnaire is that it
provides self-report data and therefore carries with it the criti-
cism directed toward the validity of a client or patient’s own
report of his or her experience. This second criticism is tem-
pered somewhat by the fact that the questionnaire is not neces-
sarily an outcome measure, nor are all of the factors consid-
ered outcomes.

SUMMARY AND CONCLUSION

Although research using Yalom’s 12-factors construct of

group therapy curative process is limited by its reliance on
self-reports, the compilation of studies from the past 10 years
provides highly useful information from one perspective: the
conscious awareness of the group members. While other per-
spectives, such as the awareness of therapists or the ratings of
&dquo;objective&dquo; observers, are championed by some researchers,
the viewpoint of the persons being treated retains considerable,
if not exclusive, -significance. The studies reviewed in this
article demonstrate an intriguing consistency with regard to
the highly ranked curative factors. The studies also ra~e issues
regarding the interrelatedness of the factors as well as the
valuing of the factors across varying groups.
Long and Cope (1980) conclude their article on curative
factors in a group for felony offenders with the following
statement: &dquo;The consistency of these findings suggests that
different types of settings and groups have little or no effect on
the perception of what is helpful in group sessions&dquo; (p. 397).
This statement is in need of qualification. The triad of self-
understanding, catharsis, and interpersonal learning (input)
show remarkable consistency as the most highly valued factors
in outpatient therapy groups, probably personal growth
groups, and some other types of small groups. Hospitalized or
partially hospitalized psychiatric patients do not evidence this
high valuing of these factors. The value of belonging to a
caring group (cohesiveness factor) seems to be a central feature

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 141

of the helping group for these patients. Thus, not only does
client population make a difference, but it may well ~ that
such things as amount and kind of structure, goals, and time
may -affect what curative factors .are observed and to what
extent they are valued.
The review of research on curative factors to date illustrates
the necessity, as well a~ provides encouragement, for further
refinement of research on the curative process in group ther-
apy. Behavioral evidence for the factors, relationships of cura-
tive factors to treatment outcome, increased specificity of the
factors for conceptual and methodological clarity, and the
significance of the lower-ranked factors are all important con-
cerns demanding further research.

NOTES

1. The study of Rohrhaugh and Barteb (1975) included both therapy and personal
growth groups. It is included in the therapy group table because most of the groups
were therapy groups.
2. Weiner’s (1974) pregroup sample was not included in determining this rank
ordering.
3. Flora-Tostado (1981) included a follow-up questionnaire on some of the
patients from the Butter and Fuhriman (forthcoming) study. Only the new subjects in
her study were used to determine the rank ordering in Table 1.

REFERENCES

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Psychology 19: 204-212.
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process: a comparison of day treatment and outpatient psychotherapy groups."
Small Group Behavior 11: 371-388.
(forthcoming) "Level of functioning and length of time in treatment factors
———

influencing patient’s therapeutic experience in group psychotherapy." Int. J. of

Group Psychotherapy.
CORSINI, R. and B. ROSENBERG (1955) "Mechanisms of group psychotherapy:
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DIES, R. R. (1980) "Current practice in the training of group psychotherapists." Int. J.
of Group Psychotherapy 30: 169-185.

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FLORA-TOSTADO, J.(1981) "Patient and therapist agreement on curative factors in

group therapy." Ph.D. dissertation, University of Utah.
LIEBERMAN, M.A., I. D. YALOM and M.B. MILES (1973) Encounter Groups:
First facts. New York: Basic Books.
LONG, L.D. and C. S. COPE (1980) "Curative factors in a male felony offender
group." Small Group Behavior 11: 389-398.
MAXMEN, L.S. (1973) "Group therapy as viewed by hospitalized patients." Archives
of General Psychiatry 28: 404-408.
MOWER, R. K. (1980) "Curative factors in counseling center therapy groups and
personal growth groups." Master’s thesis, Univcrsity of Utah.
ROHRBAUGH, M. and B. D. BARTELS (1975) "Participants’ perceptions ’curative
factors’ in therapy and growth groups." Small Group Behavior 6: 430-456.
SCHAFFER, J. B. (1975) "Changes in client’s perceptions of curative factors during a
short-term therapy group." Master’s thesis, University of North Dakota.
SHERRY, P. and J. R. HURLEY (1976) "Curative factors in psychotherapeutic and
growth groups." J. of Clinical Psychology 32: 835-837.
WEINER, M. F. (1974) "Genetic versus interpersonal insight." Int. J. of Group
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YALOM, I. D. (1975) The Theory and Practice of Group Psychotherapy (2nd ed.).
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——— (1970) The Theory and Practice of Group Psychotherapy. New York: Basic
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——— J. TINKLENBERG, and M. GILULA (1970) "Curative factors in group
psychotherapy." in I. D. Yalom, The Theory and Practice of Group Psychotherapy.
New York: Basic Books.

Timothy Butler is on the staffof the Student Counseling Service at Iowa Stwe
University ire Ames, Iowa 1~’~ c~er~t r~.~earc~ i~t~rr~,~ ir~~~r~~r©c~
irt therapy and cowiseimggrm4m

A,ddw Ftrhrir~vn is in the ~~e~~t of Educanond Psychology at the

University -~~’ Uú1h, where she is the director of the counwhng psydtoiogy
doctoral progrom..

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