Pappas, S. (2023, March 1). Group therapy is as effective as individual therapy, and more efficient. Here’s how to do it successfully. Monitor on Psychology, 54(2). https://www.apa.org/monitor/2023/03/continuing-education-group-therapy
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Group therapy sometimes gets short shrift. Viewed by some patients as second best to individual therapy and by some mental health professionals as intimidating to run, groups are mostly found in outpatient agencies and hospitals, where they are used to treat people with severe or acute conditions. In private practice, group therapy makes up at most 5% of treatment, with 95% of resources going into individual therapy.
But group therapy is as effective as individual therapy for a wide range of symptoms and conditions, and it is more efficient, allowing a single therapist to reach many people at once. In many cases, groups can be even more effective than individual therapy, thanks to the stigma reduction and solidarity that people experience in the presence of their peers.
The benefits are substantial enough that some psychologists are now calling for every private practice to offer at least one group. Meeting the unmet psychological need in the United States with group therapy would save more than $5.6 billion and require 34,473 fewer new therapists than individual therapy, according to research to be published in February in American Psychologist. If just 10% of this need was met by group instead of individual therapy, 3.5 million more people could be seen. The demand for therapy is high and rising, with 79% of psychologists reporting an increase in patients with anxiety disorders in 2022 and 64% reporting increases in patients seeking help for trauma- and stressor-related disorders, according to APA’s 2022 Covid -19 Practitioner Impact Survey. Two thirds report seeing patients with an increasing severity of symptoms compared with previous years.
“Given that group therapy is a triple-E treatment, which means it’s effective, it’s equivalent to individual therapy for most conditions, and it’s efficient, offering at least one extra group or beginning to run a group, particularly in private practice, would create enormous efficiencies in the system,” said Martyn Whittingham, PhD, a licensed psychologist in Ohio and the developer of Focused Brief Group Therapy, who led the work.
There are barriers to launching new groups, not least poor reimbursement rates for group versus individual therapy. But another key barrier is training. Group therapy was only recognized as a specialty by APA in 2018, and many psychology graduate programs offer limited instruction on group therapy skills. Psychologists can expand their skills with resources from the American Group Psychotherapy Association (AGPA) or from APA’s Division 49 (Society of Group Psychology and Group Psychotherapy).
While the details will depend on the group’s goal, putting together a successful group involves thinking not only about the structure of the group but about the interactions between group members and how those interactions can support the therapeutic process.
ADVERTISEMENTGroup therapy is as effective as individual therapy for an array of symptoms and conditions. In a recent series of 11 meta-analyses encompassing 329 studies comparing group with individual therapy, group therapy was found effective for depression and bipolar disorders, schizophrenia, anxiety disorders, social anxiety disorder, panic disorders, obsessive-compulsive disorder, posttraumatic stress disorder, eating disorders, borderline personality disorder, substance use disorders, and chronic pain (Rosendahl, J., et al., The American Journal of Psychotherapy, Vol. 74, No. 2, 2021).
Groups can be particularly fruitful for people of marginalized identities, offering support and solidarity from others with similar experiences. For instance, a meta-analysis of group interventions for trauma and depression in refugee adults and children led by Maryam Rafieifar, PhD, a social worker now at Montclair State University in New Jersey, found reduced symptoms of posttraumatic stress and depression (Research on Social Work Practice, Vol. 32, No. 1, 2022). Research has also found that group therapy can help LGBTQ+ patients cope with universal stressors and stressors stemming from coping with bias as well as other challenges related to their minority status (Craig, S. L., et al., BMC Psychology, online, 2021).
Any issues involving shame, stigma, or feelings of isolation can often be better addressed in group therapy than individual, said Amy Nitza, PhD, a counseling psychologist and director of the Institute for Disaster Mental Health at the State University of New York at New Paltz. Nitza, a past president of Division 49, and her partners in Haiti do group therapy sessions for youth sold into domestic servitude, known as restaveks. There is a great deal of shame involved in being a restavek, Nitza said, and the mental health professionals in Haiti first saw this as reason to do only individual therapy with the children. She urged them to start group treatment in 2014, and demand for the groups has outstripped supply. “It’s the healing power of finding out that other people feel the same way you feel,” Nitza said.
Groups can be either homogeneous or heterogeneous, manual or model based. These considerations can help guide who might be a good candidate for group therapy, but one of the key parameters, said Haim Weinberg, PhD, a clinical psychologist licensed in California and Israel, is the patient’s own motivation. The Group Readiness Questionnaire can help assess how receptive a patient may be to group therapy. Patients who are not ready for groups can still benefit, but may need preparation and preorientation, said Noelle Lefforge, PhD, a clinical associate professor in the graduate school of professional psychology at the University of Denver.
Therapists need to be prepared to address common misperceptions patients may have around group therapy, such as fear that they will be asked to disclose personal information they do not want to share or worries that they will have to “fix” other group members when they are overwhelmed themselves. Lefforge walks prospective group members through how the group leaders keep participants from taking on that responsibility while explaining that practicing altruism with other group members can actually improve symptoms of disorders like depression. “You really want to work with patients on getting buy-in, a collaborative appreciation for how group is going to be beneficial,” she said.
In the beginning stages of group therapy, the group leader must work to establish ground rules and foster group cohesion. Cohesion is one of the most important predictors of outcomes in group therapy (Burlingame, G. M., et al., Psychotherapy, Vol. 55, No. 4, 2018). Conflict within the group can lead to alliance ruptures, including disagreements on the tasks and goals of therapy, or a strain in the relational bond, Lefforge said. Clear rules can help establish the psychological safety that makes cohesion possible.
“Common group guidelines set the stage for how group members treat one another, how confidentiality is handled in the group setting, particularly among patients within the group, how needs might get met, how terminations are handled, how contact among group members outside of group should or should not occur or be talked about in group,” Lefforge said.
Part of this cohesion step starts with learning about and acknowledging group members’ various intersecting identities and the accompanying privilege or marginalization or both, said Eric C. Chen, PhD, a counseling psychologist at Fordham University and chair of Division 49’s Diversity, Equity, Inclusion, and Belonging Committee. Chen recommends using educator Sylvia Duckworth’s “Wheel of Power and Privilege” in pregroup interviews and during the group process to get patients thinking about the ways in which they both have privilege and are marginalized. This exercise provides a foundation for talking about individual differences that eventually surface in group discussions and for group cohesion to be built on human diversity (in Pope-Davis, D. B., et al. [Eds.], Handbook of Multicultural Competencies, Sage Publications, 2003). “I aim to utilize every group member’s past experiences of being included and excluded as a vehicle for us to empathize and connect with each other on that universal human level first,” Chen said.
Icebreakers can be useful for building cohesion, Whittingham said, and they should be tailored to the group’s needs. For instance, for patients dealing with social anxiety, he might split the group into pairs and have the pairs share personal information about each other, which is less intimidating than sharing with the whole group. But icebreakers should remain relatively brief, he warned, because participants may start feeling impatient to delve into the group’s therapeutic work.
During this introductory phase, it is often beneficial to manage ruptures carefully, Whittingham said; groups need to form a basis of trust before dealing with conflict. But gradually, conflict becomes a learning opportunity in groups. One of the most powerful aspects of group therapy is that it allows members to navigate conflict in a semisheltered social environment, Whittingham said. “The fear of conflict, for a good amount of the population, can be a very profound fear and that can really interfere with them feeling satisfied in relationships,” he said.
For someone who avoids conflict, standing up for themselves for the first time in group therapy can be a life-altering moment, he said. Likewise, someone who comes into conflicts too aggressively can get feedback on how to handle conflict more productively. Enabling this learning, though, requires the group to trust the group leader not to let conflict spiral out of control. Like cohesion, establishing a therapeutic alliance with the group will increase the likelihood of clients experiencing a safe environment necessary for a good outcome (Lo Coco, G., et al., Journal of Consulting and Clinical Psychology, Vol. 90, No. 6, 2022).
Managing conflict in groups is a delicate skill that requires the group leader to model a positive, nondefensive approach, Lefforge said. It is also about bringing conflict into the open, Nitza said. “It’s always about saying it out loud and working through it,” she said.
This is true of interactions related to race and culture in a group as well, said Aziza Platt, PhD, a counseling psychologist in Georgia who has studied microaggressions and other interactions in group therapy that may be alienating to people with marginalized identities. If someone says something in the group that might be disparaging to another group member’s identity or otherwise hurtful, Platt makes a point of stepping in—without stomping on other group members’ agency.
“What I’ll say is, ‘Hey, I just heard something that made me a little uncomfortable and I want us to explore it,’” she said. “And I’ll turn to the person who was targeted and say, ‘My sense is that was directed to you. I want to give you a chance to respond, but I’m also going to respond.’”
This strategy lets the harmed group member know that Platt will address the issue whether or not they are comfortable sharing their feelings, but it also gives them the chance to advocate for themselves, she said.
“I do a lot of work to help my groups understand the difference between conflict as generative versus destructive,” Platt said.
It is possible for groups to discuss sensitive, complex topics without arguing, she added. Indeed, Chen said, group therapy can be a place to learn how to do so, acquiring skills that will ideally help group members navigate such conversations with friends and family. “I tend to focus much less on the topics per se,” Chen said, “but more about appropriate group norms and communication processes that should be established first in order for each group member to feel psychologically safe enough for those challenging kinds of conversations to take place.”
Platt frames potential responses to racial-cultural events in group using three categories. “Antitherapeutic” responses by the group leader are reactions like, “You’re overreacting” or “That wasn’t a big deal,” directed to those hurt by a comment. “Nontherapeutic” responses are in the middle, attempting to smooth over the moment without repairing it: “I’m sorry, but let’s just move on.”
Group leaders should aim for the third option, “therapeutic responding.” This involves curiosity, empathy, a focus on the victim, and a restorative justice approach to talking through the interaction, said Platt, who recently published a practice review with clinical examples on how to address microaggressions in groups (Miles, J. R., et al., Group Dynamics: Theory, Research, and Practice, Vol. 25, No. 1, 2021).
Finally, it is important to think about how a group will end, even as it is beginning. Groups may have a time limit, with all members wrapping up together, or may have rolling attendance. Either way, it is important for leaders to think about closure for group members as therapy ends or as individuals move on. Reflection activities can be helpful, Lefforge said. A 2011 column from the Group Psychologist newsletter sums up different exercises, such as the “hope and appreciation list” activity in which each member writes down something they appreciated about each other member and a hope for each member’s future, or the “web activity” for in-person groups, in which each member passes around a skein of yarn, linking themselves to other members as they express a way in which those people impacted them. By the end of the activity, the group is linked by a web of connections.
Connection is a key concern for groups that meet online, an increasing trend thanks to a general move toward telehealth as well as the Covid -19 pandemic.
Prior to the pandemic, online groups were often considered second best to in-person, said Weinberg, who has long conducted virtual group therapy. The pandemic changed that perception, though virtual groups are still less well studied than in-person groups.
A prepandemic meta-analysis by Mayo Clinic psychiatrist Melanie Gentry, MD, and colleagues found similar outcomes between video teleconference group therapy and in-person group therapy (Journal of Telemedicine and Telecare, Vol. 25, No. 6, 2019), though most of the studies included were not designed for head-to-head comparisons. More work is needed, Weinberg wrote in a paper spurred by the pandemic, especially on questions around group cohesion, therapist presence and empathy, and whether some patients are better served online versus face-to-face (Group Dynamics: Theory, Research, and Practice, Vol. 24, No. 3, 2020). Nevertheless, said Gary Burlingame, PhD, chair of the psychology department at Brigham Young University in Utah, the evidence that has accrued is promising. A recent survey indicated that group therapists perceive online groups to be effective even if they experience challenges to managing group relationships online (Gullo, S., et al., Group Dynamics: Theory, Research, and Practice, Vol. 26, No. 2, 2022). The AGPA now includes online-specific information in its training.
Online groups are more prone to ruptures than in-person groups, simply for reasons of logistics, Weinberg said: Internet connections cut out, computers crash, cameras freeze. Weinberg said that addressing these moments head-on can become part of the process.
“Some people might feel, for example, that they are abandoned if the therapist disconnects for internet problems, or some people might feel rejected because they are not accepted back [into the virtual meeting],” Weinberg said. “There are a lot of psychological dynamics that are connected with online group therapy. . . . That’s why I say learn how to relate to anything that happens online as something that has a dynamic meaning and explore its impact.”
Because people may log in to virtual group therapy from anywhere, group leaders need to set ground rules around privacy and distraction, Weinberg said. There are also interpersonal adjustments to be made. Some people, particularly those with social phobia or a dismissive-avoidant attachment style, tend to connect better with others virtually, Weinberg said, perhaps because the screen feels protective. But therapists running online groups must adjust to the lack of physical cues such as eye contact, which can be hard to direct to a single participant via computer screen. With the increasing shift to virtual, more and more therapists are sharing strategies for working around these issues. Weinberg is coediting a book in which group therapists discuss ways they have moved their work virtual, including methods like art therapy and psychodrama, or acting out events in order to work through problems.
“One thing that is clear, from my experience,“ Weinberg said, “is that the group therapist needs to be more active, more flexible, and more creative than when we are talking about in-person groups.”
Cultural diversity, groups and psychotherapy around the world (PDF, 12.6MB)
Honig, M., & Martinez-Taboada, C. (Eds.), International Association for Group Psychotherapy and Group Processes, 2022
