Decades of research, including more than 50 clinical trials, have shown that group therapy is as effective as individual therapy for many conditions, including depression, obesity and social anxiety. Partly as a result of that research, demand for group therapy is up, and many new psychologists are being asked to lead groups in hospital and community mental health settings.
Yet the ability to run therapy groups is a special skill. In fact, APA’s Commission for the Recognition of Specialties and Proficiencies in Professional Psychology includes group psychology and group psychotherapy as an evidence-based specialty.
“Group therapy isn’t just individual therapy in a group,” says Martyn Whittingham, PhD, an Ohio counseling psychologist and president of APA’s Div. 49 (Society of Group Psychology and Group Psychotherapy). “It has its own techniques, its own processes and its own strategies, and unless you really understand those, you’re going to struggle. You need to be part of a community of people who are committed to learning and growing in this work.”
Unfortunately, many psychologists receive little training in the area.
“In most graduate programs, group therapy is an elective course, so it’s possible for students to graduate without knowing anything about group dynamics or group therapy, and take a job where they’re running groups,” says George Washington University psychology professor Cheri Marmarosh, PhD, Div. 49’s president-elect. “But without training, these students don’t know how to intervene when problems arise among members of the group, and they may not have adequate supervision. They’re just expected to go in and do it based on their individual psychotherapy training.”
How can psychologists step in to provide group therapy and ensure that their leadership meets patients’ needs? Group therapy experts offer their advice:
Get training. Taking a course on group therapy or group dynamics provides essential background on group development, conflict and how to address it in groups, as well as how to foster group cohesion, identify and repair ruptures, and deal with diversity in groups, says Marmarosh. Such training can also help psychologists better understand how to screen potential group members and how to prepare members for what to expect during the sessions.
To find such training, visit the APA Div. 49 website (www.apadivisions.org/division-49) as well as the webinars and continuing-education courses offered by the American Group Psychotherapy Association (www.agpa.org).
Compile the right group. Not every patient is an appropriate candidate for every group, Whittingham says. That’s why it’s important for the psychologist to conduct a high-quality screening and preparation interview with each potential group member before the group begins. Before these meetings, Whittingham suggests using tools such as the 19-item Group Readiness Questionnaire (GRQ), which is designed to identify risk factors for potential dropout or poor outcomes. This kind of assessment can help inform therapists’ clinical judgment so they can decide whether they need to spend more time preparing members or redirecting them to a treatment where they are more likely to be successful. “This can give you a quick look at issues that are predictive of dropout, such as low motivation or a specific type of interpersonal problem such as overt hostility or a tendency to disclose too deeply too quickly,” Whittingham says. If their assessment and individual interview suggest they may not be a good fit for the current group, perhaps their needs would be better served in individual therapy, or in a different group setting.
It’s also important to educate your referral sources about inclusion or exclusion criteria for group therapy, he says.
“You wouldn’t want to get a general group therapy referral for a client who has just gone through an intense sexual assault, for example, until they’ve perhaps gone through at least some individual therapy,” Whittingham says. “These types of clients might understandably have difficulty focusing on other people given what they’ve just been through themselves. So, it’s important to identify people’s readiness for group.”
Set expectations up front. During the initial individual intake, ask clients what they expect group therapy to look like and how quickly they expect change to occur, to ensure their hopes are in line with reality, says Roger Greenberg, PhD, distinguished professor of psychology at the State University of New York Upstate Medical University. Particularly if they say they expect to feel better within a couple of weeks, it’s important to explain that change will likely occur over a period of months.
“Remind them that it took them a while to get to the point where they were feeling uncomfortable enough to want to do something about it, and so, like everything else, it will require time to see true change,” Greenberg says.
It’s also important to dispel any notions that group therapy is conducted the same way it’s portrayed on television, Whittingham says.
“Often, clients imagine it’s going to be a lot of shouting or being attacked, so leaders need to help members understand that group can actually be a really enjoyable thing where they learn a lot from other people, not just from the therapist,” he says.
It’s also important to prepare members for possible challenges this type of therapy can present.
For example, patients who avoid conflict or disengage when relationships become difficult need to know that group discussions can become difficult. “Discuss how they might react if they experience a desire to flee, and help them commit to attending a minimum number of sessions,” says Marmarosh.
Build cohesion quickly. Some groups more naturally lend themselves to being cohesive from the get-go. “In grief groups, for example, you don’t have to work as hard to get people to feel connected once they start talking about why they’re there,” says Whittingham. However, groups without an easily identifiable common bond—those geared toward cognitive-behavior therapy, for example—might take a bit more work to help members feel connected. One strategy group leaders can use is to break the group into pairs and have them take time during the first session to get to know each other, Whittingham says. Icebreakers that encourage members to delve deeper or have fun together can also promote group bonding.
“Finding commonalities is crucial to building group cohesion, and sometimes these things emerge organically, but often the therapist will have to illuminate them for members by using linking techniques,” he says.
Including more experienced clients in the group who have already had positive experiences with this type of therapy is another smart tactic for building cohesion.
“Experienced patients are able to serve as models for how an ideal client would participate in the treatment, and this seems to enhance treatment participation and speed up the development of a sense of group cohesion,” Greenberg says.
Get feedback. Research shows that therapists cannot easily predict how well a group member is doing in therapy and whether he or she will drop out, Marmarosh says.
In addition, the field of health care in general is moving toward outcome measurements as a way to track progress and improve outcomes. Several assessment tools—some of which are free—are available to help therapists gain insight into which clients might be at risk for treatment deterioration or dropping out of therapy altogether. These include progress monitoring measures such as the Outcome Questionnaire
(OQ), developed by Brigham Young University psychology professors Gary Burlingame, PhD, and Michael Lambert, PhD, as well as therapeutic relationship measures such as the Group Climate Questionnaire (GCQ-S) and the Group Questionnaire (GQ).“Don’t trust that you can clinically jump into a member’s mind and know how they’re doing, because you can’t,” says Burlingame. “The data on this are very clear.”
Identify and address ruptures. Disagreements are almost inevitable in group therapy, but it’s important that group leaders spot and work through concerns as soon as they arise among members, Marmarosh says. Sometimes ruptures in group cohesion are obvious and confrontational, such as when a group member comments that they don’t understand how something being discussed is relevant, or if they challenge the intervention. Other times, ruptures can be more passive, with a member who begins to come late, doesn’t show for sessions, stops making eye contact or doesn’t contribute to discussions.
“You can also look for nonverbal cues, such as eye rolling, fidgeting or just looking frustrated when other people in the group are talking,” she says.
To address these issues, the therapist can gently bring it up directly with the member or with the entire group by asking if others are feeling frustrated as well, Marmarosh says.
Greenberg agrees, noting that giving clients the sense that they are an active part of the therapeutic process is one of the best ways to address discord.
“Make sure they know that you’re willing to listen and make changes that will be in line with what the client thinks they would find helpful,” he says.
Learn more about group therapy by visiting the website of APA’s Div. 49 (Society of Group Psychology and Group Psychotherapy), www.apadivisions.org/division-49/index.
Feedback in Group Psychotherapy
Psychotherapy, special issue,2018
How and Why Are Some Therapists Better Than Others? Understanding Therapist Effects
Castonguay, L., & Hill, C. (Eds.), APA, 2017
Attachment in Group Psychotherapy
Marmarosh, C., et al., APA, 2013