Integrating Spirituality Within Yalom's Group Therapeutic Factors: A Theoretical
Framework for Use With Adolescents
Author(s): Dana T. Jebreel, Ronda L. Doonan and Victor Cohen
Source: Group , Vol. 42, No. 3 (Fall 2018), pp. 225-244
Published by: Eastern Group Psychotherapy Society
Stable URL: https://www.jstor.org/stable/10.13186/group.42.3.0225
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group, Vol. 42, No. 3, Fall 2018
Integrating Spirituality Within Yalom’s
Group Therapeutic Factors: A Theoretical
Framework for Use With Adolescents
Dana T. Jebreel,1,2 Ronda L. Doonan,3 and Victor Cohen3
Many adolescents identify with spiritual beliefs, which positively impact mental health
and resilience. Group therapy has been described as optimal to use with adolescents,
because of the significant role of peer relationships and identity formation at this
developmental period. Research has shown that group therapy also provides a spiritual experience specific to adolescents. Incorporating spirituality into group therapy,
however, remains an understudied topic. Yalom’s therapeutic factors are used as a
conceptual framework to understand the spiritual constructs behind group dynamics;
thus clinicians may provide adolescents with a safe environment for spiritual growth.
The theoretical underpinnings of group psychotherapy are conducive to cultivating life
meaning, positive interpersonal relationships, and resilience.
KEYWORDS: Adolescent/adolescence; spirituality; interpersonal; cultural competence;
diversity; therapeutic factors
Over the past decade, increased attention has been given to spirituality research.
Among adolescents, there is a high prevalence of spiritual beliefs, which are associated with improved mental health and resilience (Crawford, Wright, & Masten,
2006; Raftopoulos & Bates, 2011; Smith, Oritz, Wiggins, Bernard, & Dalen, 2012).
More than 50% of adolescents state that they value spirituality, while approximately
75% of adolescents believe in a higher power, utilize prayer, or consider humans
1 We are thankful to Craig Haen, PhD, John Caffaro, PhD, Theodore Burnes, PhD, Brien Kelley,
PhD, and David Blank, PsyD, for their mentorship and feedback in improving this manuscript.
2 Private practice, Beverly Hills. Correspondence should be addressed to Dana T. Jebreel, PsyD,
450 N. Bedford Drive, Suite 204, Beverly Hills, CA 90210. E-mail: dana.jebreel@gmail.com.
3 Assistant Professor, California School of Professional Psychology, Alliant International University,
Alhambra.
issn 0362-4021 © 2018 Eastern Group Psychotherapy Society
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jebreel, doonan, and cohen
to be interconnected and transcendental (Denton, Pearce, & Smith, 2008; Higher
Education Research Institute, 2004). In a time of spiritual emergence, the recruitment
and use of spiritual traditions during adolescence is central to development (Miller,
2013). Benson, Roehlkepartain, and Rude (2003) provided a working definition of
spiritual development that encapsulates the scope and importance of spirituality
during this period:
Spiritual development is the process of growing the intrinsic human capacity for
self-transcendence, in which the self is embedded in something greater than the self,
including the sacred. It is the developmental “engine” that propels the search for connectedness, meaning, purpose, and contribution. It is shaped both within and outside
of religious traditions, beliefs, and practices. (pp. 205–206)
Spirituality develops concurrently with cognitive, moral, personality, and identity
development (Roehlkepartain, Benson, King, & Wagener, 2006). However, despite
the prominence of spiritual beliefs and the positive associations with improved wellbeing, mental health, life satisfaction, resilience, prosocial behaviors, self-esteem,
and physical health among adolescents (Desrosiers, Kelley, & Miller, 2011; Hall &
Flanagan, 2013; Marques, Lopez, & Mitchell, 2013; Raftopoulos & Bates, 2011; Smith
et al., 2012; Wong, Rew, & Slaikeu, 2006), spirituality remains underaddressed in
both the research concerning adolescents and the treatment of adolescents (Boyatzis,
2012; Denton et al., 2008).
Researchers have shown the efficacy of group therapy during adolescence, which
is a time for prominent growth and change. Widely researched, group psychotherapy
has been found to be effective for adolescents addressing issues such as anxiety,
depression, and eating disorders, increasing self-esteem, confidence, trust, peer
intimacy, and happiness (Avinger & Jones, 2007; Dennison, 2008; Lázaro et al.,
2011; Rohde, Stice, Shaw, & Brière, 2014).
Peer groups play a significant role in adolescent development and are significant
to adolescents’ spiritual growth (Goldstein, 2010; Kelley & Miller, 2007; Schwartz,
Bukowski, & Aoki, 2006). Because spirituality is interrelated with the formation
of peer relationships, and is experienced in connection with others, group therapy
has been found to provide a spiritual experience (Hall & Flanagan, 2013; Kelley &
Miller, 2007). In alignment with the research on group psychotherapy, spirituality
researchers Boyatzis (2012), Kelley, Athan, and Miller (2007), and Regnerus, Smith,
and Smith (2004) affirmed that an ecological perspective in the study of spiritual development in adolescents yields the most comprehensive understanding of
adolescent spiritual experiences. Furthermore, spirituality provides a foundational
basis for widely used treatment groups, such as Alcoholics Anonymous (AA) and
Spiritual Self-Schema (3-S; Alcoholics Anonymous, 2001; Grabbe, Nguy, & Higgins,
2012). Despite indications of its crucial relevance, there is a lack of research on the
application of spirituality to group psychotherapy for adolescents.
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Integrating Spirituality Within Yalom’s Group Therapeutic Factors
227
Aligning spirituality with group psychotherapy may ultimately aid adolescent
development within an interpersonal and existential context. While Yalom and
Leszcz (2005) did not identify the therapeutic factors inherent to group therapy
with spirituality in mind, other psychologists have understood Yalom’s (2002) work
in relation to spiritual and religious constructs. It seems as though the factors that
Yalom emphasizes in group therapy inherently facilitate spiritual awareness and
growth. However, practitioners need a clear conceptual framework to guide the
coherent incorporation of spirituality within a therapeutic group setting.
This article explores the parallels between spiritual concepts and how they manifest in group psychotherapy, using Yalom and Leszcz’s (2005) 11 therapeutic factor
framework. The therapeutic factors of universality, group cohesiveness, socialization, interpersonal learning, and imitative behavior have particular developmental
significance to adolescence (Akos, Hamm, Mack, & Dunaway, 2006). This framework
serves as a way to recognize how spirituality can be delineated in group therapy,
as the therapeutic factors and spirituality share similar constructs. An improved
understanding of how to integrate spirituality into group psychotherapy will inform
clinicians to further address each adolescent holistically. Group psychotherapy is
conceptualized through a spiritual lens to understand how the factors can bring
adolescents closer to themselves, others, and transcendence. Understanding the
parallels of spirituality within Yalom’s framework will maximize the potential of
spiritual application for therapeutic healing and resilience building and stand as a
building block for future research. Clinicians can formulate interventions, treatment plans, and conceptualizations based on this theoretical framework. Clinical
applications are presented to demonstrate how this framework can be applied.
INTEGRATING SPIRITUALITY WITHIN YALOM AND
LESZCZ’S GROUP THERAPEUTIC FACTORS
Instillation of Hope
A vital factor in group therapy and a significant component of spirituality is the instillation and preservation of hope (Rayner & Montague, 2000; Yalom & Leszcz, 2005).
Hope has been linked to positive therapeutic outcomes (Burlingame, Fuhriman, &
Johnson, 2001). Because spirituality encourages adolescents to be hopeful and find
meaning in life circumstances, researchers have further identified spirituality as a
central feature of resilience (Min et al., 2012; Rayner & Montague, 2000). Utilizing
spirituality promotes this resilience and aids in the cultivation of hope (Burlingame
et al., 2001). In a group setting, instillation of hope is imparted as members witness
each other’s improvement over the course of a group experience (Yalom & Leszcz,
2005). Adolescents can develop positive internal processes, including the ability to
see past the current stress and hurt of peer relationship struggles (Hall & Flanagan,
2013). This sense of hope can foster spirituality within adolescent group members,
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jebreel, doonan, and cohen
228
and conversely, spiritual beliefs can assist the instillation of hope that is essential
to a group process (Yalom & Leszcz, 2005).
Universality
Spiritual experiences are characterized by a sense of connection with others and a
oneness with the universe (Newberg & Newberg, 2005). Yalom and Leszcz (2005)
suggested that universality is achieved through the sharing of group members’ life
experiences. This factor is especially pertinent to adolescents, who may feel that
no one else has experienced their current feelings. Through interpersonal group
interactions, adolescents hear other group members’ similar painful experiences
and begin to develop empathy for others, feeling less isolated in their difficulties
(Akos et al., 2006).
This sense of commonality parallels spiritual themes. Interpersonal relationships
allow development of compassion toward others and a feeling of connection with
something that extends beyond oneself (Schwartz et al., 2006). Discussing shared
values and beliefs with peers facilitates stronger spiritual beliefs, creating a sense of
connection to something outside of the self. Schwartz and colleagues (2006) compared this feeling to transcendence, as friendships encourage adolescents to look
beyond themselves and view their being as part of a greater whole. If therapists can
utilize the factor of universality to help the group see past individual and cultural
differences and connect through shared human experiences, healing can transpire
through the spiritual element of connectedness (Pehler & Craft-Rosenberg, 2009;
Yalom & Leszcz, 2005).
Imparting Information
Components of this therapeutic factor include didactic instruction given by group
therapists and direct advice or suggestions from group members (Yalom & Leszcz,
2005). Group members benefit from didactic instruction on spiritually oriented
techniques, such as mindfulness, meditation, prayer, reflection, and forgiveness
(Hill & Pargament, 2003), to encourage personal growth and recovery. Members
can be encouraged to share activities that they associate with their spirituality, such
as music, art, and nature-led experiences (Astrow, Pulchalski, & Sulmasy, 2001). A
group member who practices more action-oriented spirituality may express spirituality through music and prayer. A group member can hold strong spiritual values
without belief in a deity (Mohr, 2006). This group member may gravitate toward
this nonjudgmental and inclusive environment.
Second, Yalom and Leszcz (2005) stated that the content is less significant
than the action of giving advice, as the action implies care and interest for one
another. The development of cognitive capacities allows adolescents to focus on
abstract ideologies that underlie action (Cartwright, 2001) and to search for spiritual
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Integrating Spirituality Within Yalom’s Group Therapeutic Factors
229
guidance from social relationships (Schwartz et al., 2006). For those receiving
advice, the experience of feeling supported reflects spiritual values of community
and social support (Crawford et al., 2006).
This factor also prepares group members for the culture of group therapy, which
can be shocking or fear provoking (Yalom & Leszcz, 2005). If group preparation
is skipped over or misunderstood, adolescents may be unwilling to engage in the
spiritual group process (Erikson, 1959). Clinicians can lay a foundation for safety by
setting a framework for how spirituality may be utilized within the here-and-now
process of the group.
Altruism
Help and support for others characterize this factor, instilling a sense that group
members have something valuable within themselves to offer to others (Yalom &
Leszcz, 2005). Once an individual becomes useful to another person, he or she is given
a sense of purpose, meaning, and happiness that is a result of the pure giving, not
the motivation to receive in return (Yalom, 1974). This is similar to the life purpose
and meaning gained from self-transcendence (Frankl, 2014), which researchers have
identified as a strong component of spirituality (Astrow et al., 2001; Kim & Esquivel,
2011; Raftopoulos & Bates, 2011; Smith et al., 2012). Adolescents may feel less of a
burden to others as they become useful and build their self-esteem (Maslow, 1956).
Altruism is a frequent practice in spiritual communities and AA groups, brought
into group therapy as members are given the opportunity to extend themselves
and contribute to others’ lives (Yalom & Leszcz, 2005). For example, AA members
remain involved long after maintaining a sober lifestyle, and in many spiritual and
religious communities, it is commonplace for individuals, particularly the ill, to
pray for one another (Yalom & Leszcz, 2005).
The Corrective Recapitulation of the Primary Family Group
Because an adolescent’s spiritual development is connected to his or her experiences
with others, including family, friends, and a higher power (Goldstein, 2010), this
factor has particular relevance to current developmental challenges, such as gaining
autonomy from the family, resolving family conflict, and developing personal identity
(Erikson, 1959; Raftopoulos & Bates, 2011). Yalom and Leszcz (2005) emphasized
that within the group process, reliving familial conflicts can lead to reparative experiences. In a spiritual context, this factor could include any force, object, animal,
human, or being with whom the adolescent has a relationship, thus widening the
scope of possible reparative relationships. Wade, Worthington, and Meyer (2005)
suggested that it is beneficial for individuals to explore emotions toward individuals
who have hurt them. The therapy group appears to be an appropriate, safe context
in which to do so, as Yalom and Leszcz encouraged interpersonal work in the here
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jebreel, doonan, and cohen
and now. Spirituality can facilitate a corrective experience, as group members
may gain compassion and forgive people in their lives through understanding the
emotional processes of those with whom they currently engage (Hill & Pargament,
2003). Utilizing the healing aspects of spiritual beliefs in therapy can aid adolescents
to cope with their experiences and move beyond pain (DiBlasio, Worthington, &
Jennings, 2013; Raftopoulos & Bates, 2011).
More specifically, spirituality has been found to have positive effects on stressors,
including changing family dynamics (Brown & Robinson, 2012). In a study of resilience in remarried families, spirituality items, such as prayer and the presence of a
higher power, strengthened family members to tolerate changing family dynamics,
whereas religious items were insignificant (Brown & Robinson, 2012). Raftopoulos
and Bates (2011) noted that adolescents used spirituality in dealing with low-point
and difficult experiences to generate a sense of meaning and purpose, manifested
in a transcendental connection, as well as a connection with the inner self. Participants who drew strength from having a sense of meaning and purpose were able to
see the opportunity for self-growth in their low-point experiences. Thus the group
can be an experimental format in which group members practice their resilience.
Spiritual struggles may also be reenacted within the group, as adolescents may
discover negative feelings toward their deity. Pargament (1997) claimed that some
religious beliefs related to the transcendent nature of spirituality could cause negative coping patterns, such as feeling punished by a higher power. These dispositions
may manifest as anger, disappointment, or unrealistic expectations toward the group
leader. For example, a group member may discuss his or her animosity toward his
or her G-d.4 Upon exploration by the group leader, the member may identify the
group leader as someone toward whom they feel animosity. The group member
can thus use the group leader to have a reparative experience. However, a healthy
connection with the group leader may develop into the positive connection many
adolescents describe having with a higher power, G-d, angel, or other “nonphysical” force (Raftopoulos & Bates, 2011, p. 161). This connection with the group leader
gives participants a sense of comfort, accessibility, and security that they are always
being supported, particularly in times of need.
Development of Socializing Techniques
Group members frequently develop sophisticated social skills, regarded as a relevant
therapeutic factor pertinent to adolescent development (Akos et al., 2006; Yalom
& Leszcz, 2005). Once a personal connection has been established in a safe environment, more emotional and interpersonal experimentation will appear, creating
interpersonal feedback necessary for self-reflection, motivation for change, and
insight into identity (Tomasulo, 1998; Yalom & Leszcz, 2005).
4 For the purposes of this article, the word “G-d” will be used in place of the complete word.
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Integrating Spirituality Within Yalom’s Group Therapeutic Factors
231
As a result of the cognitive changes adolescents undergo, they begin to experience
complex socialization, and their ability to relate on a more spiritual level deepens
(Cartwright, 2001). Spirituality promotes positive identity formation (Goldstein,
2010) and is interrelated with forming peer relationships. “Humans are intrinsically
motivated to develop a spiritual identity in order to satisfy their need for connection” (Templeton & Eccles, 2006, p. 256). Adolescents’ spiritual identity develops
within a social context in that they experience spirituality through their relationships and form positive spiritual identities largely influenced by peers (Boyatzis,
2012; Goldstein, 2010). Because connection with others is a significant component
of spirituality, this therapeutic factor can aid group members to self-reflect and
actualize the relationships they may desire with others.
Imitative Behavior
Yalom and Leszcz (2005) said that learning from and identifying with other members
or the facilitator is common in the early stages of group therapy and paves a path for
further experimentation. Understanding adolescent development informs a group
leader about adolescent group behaviors. Fowler and Dell (2006) have typically
placed emerging adolescents in the synthetic–conventional stage, in which they
are highly aware of others’ expectations and perceptions. Because early adolescents
want to live up to society’s expectations, their values are highly impacted by external forces; they start to form their identities, without serious reflection, mainly
by conforming to the values and beliefs of significant peers, family, or adults. Thus
their spiritual identities are largely rooted in their connections to others, particularly friends and family (Goldstein, 2010). Because early adolescents look to others
for behaviors, seeing how others handle similar struggles can help to teach them
positive ways to deal with their problems. In a homogeneous spiritual group, peers
may serve as role models for how to live a religious or spiritual life (Kelley et al.,
2007). Older adolescents in the individuative–reflective stage now critically reflect
and question their own and others’ thoughts and beliefs; they may rebel as they
experiment with their developing identities (Erikson, 1959; Fowler & Dell, 2006;
Kelley et al., 2007). Higher cognitive capacities may cause adolescents to become
argumentative, question group rules, and challenge the group leader and members.
These conflicts are an opportunity to help adolescents become more accepting of
differences between people, express their opinions, and practice conflict resolution
(Akos et al., 2006).
Schwartz and colleagues (2006) studied spiritual development in a social context
beyond that of parents and family, examining the social relationships of mentors,
friends, and gurus, all of whom were described as having a significant spiritual influence on adolescents. Thus the group leader’s spiritual influence may also weigh
heavily on the adolescent group members as they start to experiment and adopt
coping strategies and new perspectives. It is critical for the group leader to work
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jebreel, doonan, and cohen
through his or her personal spiritual beliefs, struggles, and practices and, most
importantly, to be aware of how his or her shortcomings may affect the group.
Interpersonal Learning
Goldstein (2010) found that adolescents most often experience spirituality through
their relationships with others, particularly with family, friends, self, and a higher
power. Participants reported their self-transcendent experience as “feeling connectedness with someone, somewhere, something beyond the self and can include such
process as searching for meaning, purpose, and connection” (p. 12). This therapeutic
factor appears to directly impact the spiritual factor of transcendence, as researchers
found that, for adolescents, meaningful relationships strengthened transcendental
relationships that positively affected their well-being (Desrosiers et al., 2011).
Yalom and Leszcz (2005) indicated that healthy interpersonal relationships
are central to individuals’ functioning and that the therapy group provides a “social microcosm” that allows for a corrective emotional experience to occur. Each
member’s interpersonal style reenacts within the group dynamics in the here and
now, allowing group members to reflect on their interpersonal patterns. Significant
therapeutic factors, such as cohesiveness and group support, create an environment
that allows adolescents to work through challenging group events, thereby helping
them to develop healthy communication, the ability to express and receive love,
and trust (Yalom & Leszcz, 2005).
In a review of the fifth edition of Yalom and Leszcz’s (2005) The Theory and
Practice of Group Psychotherapy, Caffaro (2007) emphasized the difference between
showing and telling in the process of experiential change. The individual must experience change rather than being trained how to change. Adolescents’ cognitive, moral,
and emotional advances allow them to engage in more complex relationships; thus
experiential change can occur. Adolescents have a deeper ability to use their skills
in perspective taking to allow for empathy, they have a more developed capacity
for emotional expression, and their abstract thinking and problem solving allow
for planning and experimentation (Roehlkepartain et al., 2006; Yalom & Leszcz,
2005). Furthermore, as children transition to adolescence, they spend increasingly
more time with their friends and less time with their parents (Larson, 2001). This
prominent developmental task of forming relationships becomes more complex
during adolescence; youths need skills to help navigate both the rewarding and
challenging aspects of interpersonal relationships, particularly as more intimate
peer relationships also cause stress and hurt, such as from bullying, victimization,
social exclusion, and gossiping (Hall & Flanagan, 2013; Schwartz et al., 2006).
This factor gives adolescents the opportunity to experiment with complex relationships in a therapeutic environment and to explore their spiritual beliefs in the
context of peer relationships. Through acts such as encouragement, forgiveness,
sharing, challenging, listening, and engaging with peers, adolescents become sensitive
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Integrating Spirituality Within Yalom’s Group Therapeutic Factors
233
to each other’s needs, resolve conflicts, and develop strong connections (Quagliana,
King, Quagliana, & Wagener, 2013; Schwartz et al., 2006). Meditation and prayer
can also facilitate group members’ healing (Quagliana et al., 2013; Wisner, Jones, &
Gwin, 2010). Spirituality can be used to foster an exploration of life meaning and
personal identity to help adolescents cope during this tumultuous, sensitive time
(Benson et al., 2003; Boyatzis, 2012; Desrosiers et al., 2011; Goldstein, 2010; Miller,
2013; Regnerus et al., 2004).
In the context of peer relationships, spirituality/religiosity was found to increase
resilience and decrease maladaptive coping, as many verbal and nonverbal spiritual teachings promote compassion, empathy, and love (Hall & Flanagan, 2013).
Adolescents use their spiritual beliefs and values to make sense of difficult peer
relationships. Benson and colleagues (2003) asserted that addressing adolescents’
spirituality/religiosity will promote the use of their personal and contextual spiritual
resources and aid them in applying their beliefs and values in social environments.
Peer conflict in the group presents an opportunity for interpersonal learning.
Group Cohesiveness
Yalom and Leszcz (2005) stressed the significance of group cohesion and its high
impact on the productivity and attendance of the group. The stronger the attraction an adolescent feels toward the group, the more effective the group process will
be; thus group cohesion lays the foundation for the other therapeutic factors to
occur. Yalom and Leszcz emphasized that cohesiveness allows for group sharing
that leads to acceptance, membership, and approval pertinent to an adolescent’s
developmental stage. This sense of belonging is similar to the belonging discussed
within adolescent spirituality.
Adolescents experience a developmentally normal task of a search for connectedness with others and are driven by a desire to engage in relationships that fulfill
their needs of acceptance, belonging, and approval (Benson, Scales, Hamilton, &
Sesma, 2006; Yalom & Leszcz, 2005). Adolescents need physical and emotional
safety to accept others and feel a sense of belonging with family or friends (Yalom
& Leszcz, 2005). A healthy sense of belonging will allow for the development of
self-esteem (Maslow, 1956). In turn, who an individual wants to be is impacted by
his or her self-perception and self-esteem. When the stage of self-esteem is fulfilled,
adolescents are motivated to discover their identity and reach the potential of who
they want to be. Smith and colleagues (2012) described that some spiritual values
promote the importance of community and social support; therefore individuals
are encouraged to use the group as a form of support and belonging (Crawford et
al., 2006).
Yalom and Leszcz (2005) discussed this factor as comparable to the therapeutic relationship between client and therapist in individual therapy. Rogers (2012)
outlined that, as a result of a positive client–therapist relationship, clients become
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jebreel, doonan, and cohen
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more self-aware and expressive, develop a stronger self-concept, and experience
unconditional positive regard from the therapist. The latter mirrors an individual’s
relationship with a transcendental power, as client–therapist relationships have also
been compared to relationships with a higher power (Luhrmann, 2013). However,
group cohesiveness includes the group member–therapist relationships as well as
the group members’ relationships to other members and to the group as a whole.
Yalom and Leszcz (2005) stated that attention must be paid to the composition
of the group and that it is not necessary to create a diverse group, as diversity will
emerge in homogeneous groups. For example, a group composed of adolescents
interested in exploring their spirituality and applying spiritual concepts to their
group process may appear as homogeneous, but diversity will most likely exist, as
individuals differ in their beliefs, values, and practices. In comparison to adolescents’ social environments, adolescents are found to select friends who share similar
behaviors, beliefs, and developing identities (Akers, Jones, & Coyl, 1998). Thus a
homogeneous group will mimic adolescents’ natural social environment, while
allowing for heterogeneity to occur naturally, leading to more group cohesion and
immediate support that create an environment in which adolescents can tolerate
and grow from conflict.
Catharsis
Although crucial to the group process, Yalom and Leszcz (2005) suggested that
catharsis, or open expression, is a necessary adjunct to interpersonal learning and
not a sufficient therapeutic factor on its own. Emotional expression is related to
hope, sense of self, and positive coping, similar to aspects of spirituality. Beyond
venting and open disclosure, catharsis releases suppressed emotions and allows for
an inner experience to be expressed, promoting healing. Telling one’s personal story
and being able to process emotions in the presence of others can lead to a relief
of emotional weight and cleaning of negative emotions from the body (Wimberly,
2011). Tomasulo (1998) added that this factor is beneficial not only for the individual
venting but also for those observing, as they witness expression in others that encourages their own expression of emotion.
Kelley and colleagues (2007) found that adolescents need time and space to
internalize their spiritual beliefs and experiences, which in turn facilitate the development of spirituality. Interpersonal openness enhances spiritual and religious life;
open discussion about spirituality leads participants to openly discuss their struggles;
and peer openness provides spiritual support. Being listened to and witnessed can
provide a powerful forum to be received by others, allowing for emotional processing, meaning making, and the space to clarify and question their authentic selves.
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Integrating Spirituality Within Yalom’s Group Therapeutic Factors
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Existential Factors
Existential therapy is concerned with conflicts within issues of human existence,
such as death, freedom, and the meaning of life (Yalom & Leszcz, 2005). It can seem
like a great challenge to find purpose in a world that can present as meaningless,
in which it can be difficult to create connection. Erikson posited in his 1959 model
of psychosocial stages of development that adolescents encounter a psychosocial
crisis and ask existential questions about their being. Erikson said that adolescents
develop their identity and are challenged by a sense of confusion about who they
want to be and what roles they want to embody. This confusion is manifested
through rebellion and identity diffusion. They begin to question and reassess their
identities and form systems of values that are most appropriate for them. Successfully developing this identity enables adolescents to become resilient and handle
life’s challenges effectively (Erikson, 1959). Himelstein (2011) presented the use
of transpersonal psychotherapy, informed by existential and spiritual theories,
in working with incarcerated adolescents. Because transpersonal and existential
therapy concentrates on self-awareness, present and authentic experiences, exploration of one’s personal spirituality, and interpersonal relationships, including the
client–therapist relationship, the practice of this theory encourages change in that
its accepting nature and exploration of resistance cause adolescents to be more open
to personal transformation (Himelstein, 2011).
Yalom, Tinklenberg, and Gilula’s unpublished manuscript (cited in Yalom &
Leszcz, 2005) led to the addition of existential factors, described by Yalom as an
afterthought. The authors provided a new category of existential statements, and
participants highly ranked these statements concerning their experience within a
group. Yalom claimed that these findings brought many of life’s truths to light (Yalom
& Leszcz, 2005). Several of the existential factors infiltrate other therapeutic factors,
such as altruism and interpersonal learning. For example, Yalom (1974) explained how
those who take responsibility for their behavior are able to engage in change and that
individuals who extend themselves to others gain life purpose and meaning. Yalom
(1974) stated that the “presence” of the therapist alone is enough to give comfort to
a patient facing death. Through sitting with a client’s pain, the group connects and
joins in shared experiences. Although the dying patient is alone in his or her death,
the group members are still also facing their own deaths; thus all members are “apart
from but also a part of ” the group (Yalom, 1974, p. 35). Adolescents reinforce their
personal existence through facing these challenging life questions and exploring
beliefs in the context of peer relationships (Kelley et al., 2007).
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236
jebreel, doonan, and cohen
ETHICAL AND CULTURAL CONSIDERATIONS FOR
SPIRITUALLY INFORMED GROUP PSYCHOTHERAPY
In light of the cultural and individual complexity of spirituality, and alluding to
the importance of clinical competency, Yalom (as cited in Edelstein, 2007) stated
in an interview,
I have a lot of trouble with the concept of spirituality, and every time someone uses the
term I can’t discuss it with them until I find out exactly what they are thinking. . . . Some
people talk about a sense of awe and magic in the universe, looking at the skies and the
cosmos, their sense of smallness, and the glory of the heavens. . . . So I want to find out
exactly what spiritualism is for that person. It comes in a rainbow of flavors. (para. 17)
Spirituality has different implications across religion, culture, ethnicity, and gender
and should be addressed in a way that is attuned to an adolescent’s background
(Comas-Diaz, 2012). Learning about a client’s spiritual orientation is critical to
practicing spirituality in therapy. Assessing for group members’ spiritual beliefs,
learning their spiritual language, and knowing their spiritual and/or religious resources to understand their outlook on their spirituality are emphasized (Plante &
Thoresen, 2012; Raftopoulos & Bates, 2011; Richards, 2012).
Mattis, Ahluwalia, Cowie, and Kirkland-Harris (2006) discussed the complexity
of ethnicity and culture related to adolescent spiritual development. They emphasized
the importance of understanding that, in Western cultures, spiritual and secular
are distinct spheres, unlike the manifestation of spirituality in other cultures. For
example, a Native American individual who presents with a physical ailment and
believes in the connections among mind, body, and spirit will require a response
from the group leader that elicits exploration about a spiritual struggle rather than
an emotional one (Trujillo, 2000). Numerous differences exist in how communities
make meaning of the term spirituality. Beyond relational and moral associations,
in some cultures, spirituality encompasses the belief in supernatural forces, such
as in Haitian culture, where spiritual beliefs related to voodoo or the evil eye can
cause mistrust (Desrosiers & St. Fleurose, 2002). Spirituality can also be viewed as
a state of being or a progression. Some cultures have rituals and markers for spiritual transitions that happen in adolescence, while in some African American and
Caribbean communities, children are viewed as reincarnations of family spirits that
bring wisdom into the world (Magesa, 1997). In conclusion, Mattis and colleagues
(2006) made a strong point that the meaning of the relationships among culture,
ethnicity, religion, and spirituality must be explored to understand adolescents’
spiritual values and conflicts.
Comas-Diaz (2012) discussed the term colored spirituality—people of color’s
spirituality that encourages consciousness, resilience, and liberation based on cultural contexts and histories. Most pertinent in Comas-Diaz’s writings, the author
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Integrating Spirituality Within Yalom’s Group Therapeutic Factors
237
introduces an “invisible altar” (p. 199), in which people of color disguise their spirituality because of cultural oppression. Paradoxically, spirituality is interconnected
with healing for many people of color, supporting the stance that, if people of color
connect with their spiritual heritage, they develop coping skills, leading them to
become empowered.
Clinicians should also be aware of how gender affects the expression and process
of spirituality. Tirri, Tallent-Runnels, and Nokelainen (2005) found that girls express
spirituality differently than boys, by asking more spiritual questions. These findings
are consistent with the findings of Desrosiers and Miller (2007) that adolescent girls
have higher magnitudes of relational spirituality, most likely due to their stronger
emphasis on identity development and social coping rooted in their relationships.
Furthermore, it is recommended that clinicians who desire to use spirituality
in their practice should prepare for sessions both professionally and personally by
developing their own spiritual connections, as those therapists who participate in
personal spiritual growth find their treatment becomes more effective (Richards,
2012). Zinnbauer and colleagues (1997) found that mental health professionals
self-identified on the continuum more closely as spiritual but not religious, rating
religiosity more negatively. The authors claimed that this is a red flag for mental
health professionals, who may project their beliefs onto clients, potentially becoming a difficulty when working with clients who integrate religiosity and spirituality.
By developing competence, therapists will maintain ethical standards in their work
and be seen as more credible by their clients, understand spiritual ideas on a deeper
level, and know how to access their clients’ resources.
POTENTIAL CLINICAL APPLICATIONS
In addition to spirituality groups, such as AA and 3-S, the literature discusses
spirituality-oriented interventions, such as applying prayer, forgiveness, and meditation (DiBlasio et al., 2013; Quagliana et al., 2013; Wisner et al., 2010). This article
looks outside of spirituality interventions that can be applied to groups and studies
the innate factors in group psychotherapy that foster spirituality. Clinicians may be
hesitant to use spiritual interventions in groups, reflected in the difficulty of integrating spirituality into the wider literature. In this hypothetical case example, the
authors attempt to illustrate the wider constructs that emerge in a group and how
the theoretical principles from Yalom’s 11 therapeutic factors can be used through
a spiritual lens in clinical practice. The factors of universality, altruism, instillation
of hope, and imparting of information specifically demonstrate the convergence of
Yalom and Leszcz’s (2005) therapeutic factors and spirituality with adolescents.
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jebreel, doonan, and cohen
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Case Study
Lucia is a 15-year-old African American female participating in a group for female
adolescents ages 15 to 17 years who are struggling with depression. The eight-member
group has met weekly for four months. Lucia joined the group as a referral from
a nearby hospital, where her mother is in treatment for cancer. For the first three
months in the group, Lucia helped others but noted no personal benefit from the
group and saw herself as an outsider in the group until this point.
Over the course of the group, members have disclosed their struggles, creating
perspective for Lucia that her struggle and pain are not unique to her. The therapist
facilitates this understanding by using terms that not only reference the group as a
microcosm of a family, for example, but also the world and the universe. Terminology such as nature, G-d, people, dimensions outside of our senses or consciousness,
intuitiveness, and gut thoughts and feelings are used to help adolescents connect their
group experience to a greater whole and to transcendence. As cohesion develops,
Lucia slowly develops the viewpoint that she is part of a greater whole; just as she
is connected to the group, she has a relationship with all of creation. Furthermore,
witnessing other members’ change and progress instills hope. Lucia questions the
benefit of this group for the positive and starts to build her resilience in confronting
her challenges. These factors of instillation of hope and universality help Lucia use
the group as a format to experiment in sharing more aspects of her life.
As the group had previously learned, Lucia experiences her spirituality interpersonally and through music. In light of the importance of inquiring about group
members’ spiritual beliefs and practices, the group leader had engaged the group
in self-reflective exercises early on. Through this, the leader was informed of the
spectrum of spirituality within the group and helped bring forth the group’s spiritual
resources, connections, and experiences. To move away from religious practices,
the facilitator asked about the group’s experiences with spirituality and used that as
a platform for learning about how members express their spirituality, for example,
through behaving (actions, rituals, holidays, doing), belonging (community, culture,
history, believing (faith, meaning), and/or being (experience; Goldberg, 2013). It is
important to ask what experiences or feelings members associate with spirituality,
whether or not they acknowledge or connect with a higher power, and how they
connect with worldwide themes, such as “love, meaning and purpose, belonging,
forgiveness, community, honesty, family” (Richards, 2012, p. 248). Lucia described
that when she sings with others, she is reminded of the greatness of the world and
the power people have to add positivity to the universe. Singing gives her a sense
of calm, knowing that the hardship in her life, although difficult, is part of a greater
whole. In viewing the group through a spiritual lens, the facilitator understands that
the therapeutic factor of universality is beneficial to Lucia’s growth in the group and
can serve as a spiritual resource for her.
It is the value of the group that members can become attuned to their spiritual
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Integrating Spirituality Within Yalom’s Group Therapeutic Factors
239
selves. Therefore, when Lucia shares more of her inner world with the group, and
discloses her pain over her mother’s illness, the group leader asks Lucia and the
members what they “see” or “hear” from Lucia, to foster intuitive senses in the
moment. This helps the group move into an ethereal space and allows for spiritual
resources to come up in the moment. By using the moment, members say that they
want to pray for and send positive regard to Lucia and her mother. A member says
that she wants to sing to Lucia, as she knows that was something that calmed her,
but does not know what songs she connects to. In response, the group leader asks if
Lucia would like to teach a song to the group, to which Lucia agrees, on the condition that the group sing the song together after being taught. To maintain comfort,
the group discusses that some members would like the option to hum the tune
rather than sing. This proposal allows for the group to find altruism and catharsis.
Each member will be able to contribute to this communal giving, both in a way that
Lucia wished for and in a personal way that will be authentic for each member. This
imparting of information is brought into the group not only by the direct activity
but also by the dialogue that follows. Lucia chooses a song about healing that was
passed down in her family. She starts to feel her altruism in the group as she offers
the group something beyond her pain. The group is literally participating in imitative behavior in a way that is mirroring, relatable, and an opportunity to join the
group and experiment with their levels of comfort.
As Lucia connects to others in the group through the development of socialization
techniques, she begins to reflect upon her identity and solidify her spiritual beliefs
through the support she receives from the group. As group members experience
peer support, they also strengthen their spirituality through the instillation of hope.
The compassion gained toward others strengthens the feeling of connection with
something that extends beyond oneself. When confronting her mother’s illness and
possible death, existential factors are addressed while Lucia is making meaning of
her experience, life purpose, loss, and the fate of the group.
CONCLUSION AND FUTURE DIRECTIONS
Yalom and Leszcz’s (2005) qualitative findings and conceptual therapeutic factors
closely resemble the spiritual constructs discussed. This article utilizes Yalom’s group
psychotherapy framework to increase opportunities for spiritual development, as
the therapeutic factors are conducive to facilitating spiritual growth. Adolescent
development is strongly considered alongside adolescents’ developmental stage in
spirituality. This article attempts to bridge the gap between spirituality research and
therapeutic practice, specifically using group psychotherapy. Within the discussion
of the 11 therapeutic factors, group psychotherapy is explored through a spiritual
lens to understand how these factors can bring adolescents closer to themselves,
others, and transcendence.
In conclusion, the authors believe that spiritually informed group psychotherapy
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is one way to therapeutically and inclusively support adolescents. It is important to
note that the conclusions of this article need to be viewed through the understanding
that spirituality remains understudied. However, the field of spirituality is growing,
indicating an emergence of awareness of spiritual orientations. This is an exciting
time to investigate the range of spiritual group processes. Based on the proposed
theoretical framework, it is the authors’ hope that future researchers will continue
to focus on the wide range of spiritual orientations, beliefs, and practices within
various cultures. It is of significance that the referenced literature covered the ages of
10 to 24 years, although the majority of the research focused on ages 14 to 19. Future
researchers should continue to investigate the differences in spirituality within the
wide range of adolescent development. Researchers can create subgroups within
adolescence to compare how spirituality manifests during different developmental
periods. Although it has been found difficult to research the abstract concepts of
group psychotherapy, practitioners can benefit from researching the efficacy of
spirituality in group psychotherapy with adolescents. Research on leadership styles,
conceptual orientations, and empirical research of spiritually based group outcomes
will enhance the understanding of the efficacy of such groups. As the research
broadens, practicing clinicians may be further informed by a deeper understanding
of how adolescent spirituality manifests into negative coping strategies. Researching
spirituality specifically pertaining to the practice of group psychotherapy is of deep
value to this developing field.
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