Group Therapy

Function

Creating a Group

Groups often rely on referrals from other mental healthcare professionals, and a healthcare professional should ideally have a wide referral base. Given the logistical challenges, a healthcare professional running multiple groups should consider hiring a program coordinator. When establishing a group and handling referrals, the therapist must consider several key factors:

• What is the purpose of the group in helping clients? 
• A specific traumatic event, such as survivors of a disaster.
• A specific diagnosis, such as obsessive-compulsive disorder.
• A specific set of skills, such as social skills.

• How homogenous or heterogenous is the group?
• Does the group consist of a gender or an age group?
• The group should have sufficient similarity between members to allow for the formation of group cohesion.
• Each member should be able to readily identify with at least one other member.
• Sufficient heterogeneity helps the group function as a microcosm for the outside world. 

• How long does the group run?
• Groups can be close-ended, lasting a specific number of sessions.
• Groups can be open-ended and last as long as the healthcare professional is able and willing to conduct sessions. 
• Sessions typically last 90 to 120 minutes in most treatment approaches.

• How many members does the group have, and under what circumstances does the group accept new members?
• Having too many members may exclude some clients from discussions and blur the group's focus.
• Groups typically have 7 to 10 members in most treatment approaches.
• Losing or accepting too many members at a time can affect group cohesion and treatment efficacy.

• Is a co-therapist involved?
• Having 1 therapist provides clarity.
• Having 2 therapists provides richness (more relationships) and smoother logistics as therapist absences and documentation are less problematic.

• The location of the group, the layout of the therapy setting, the day of the week, and the time of day for the group session. 
• The location should afford privacy for the group members.
• The layout should not emphasize any particular seat and often be a circle of chairs.

Identifying Suitable Clients

After designing the group, the group leader should carefully select clients suited to the group's structure and goals. Exclusion criteria are relative rather than absolute. However, clients in acute distress are unlikely to tolerate group therapy and may have difficulty providing appropriate support and insight to the other group members. Low motivation for treatment, noncompliance with rules, and incapacity for connection with others are relative contraindications unless the group's design accounts for these features, such as with group therapy for antisocial personality disorder.

Other selection methods for group members include individual interviews, small group experiences, or psychological testing such as the Group Therapy Questionnaire, Group Selection Questionnaire, or NEO–Five-Factor Inventory to determine a candidate client's suitability.[5] Evidence shows that high extroversion and conscientiousness predict success, and high neuroticism predicts treatment failure.[6][7][6]

The group leader orients the individual members to the structure, function, and goals of the group. The healthcare professional must discuss the group norms regarding fees and attendance with each member. Proper preparation reduces dropout rates and enhances attendance, ultimately improving group cohesion.

Group Leadership

Healthcare professionals leading group therapy can be psychiatrists, nurse practitioners, psychologists, social workers, nurses, rehabilitation therapists, occupational therapists, or vocational rehabilitation therapists. Group therapy providers use techniques that enhance the therapeutic factors that predict treatment success. The group leader fulfills the executive function and guides the group to correct misunderstandings and behaviors. The group leader must demonstrate a strong belief in group therapy as an effective treatment, as clients seek guidance from the therapist in the early stages of the group. The group leader must be optimistic and demonstrate a genuine capacity for caring and empathy so that the clients feel hope and safety.

As a therapist, the group leader must be self-aware, as the group sometimes idealizes the therapist as a master who may shame them for not living up to expectations. In addition, the therapist experiences both subjective countertransference due to the therapist's dynamics and objective countertransference due to the group's dynamics, which need to be identified and managed by the therapist. Patients may project their self-representations (concordant identification) or object representations (complementary identification) onto the therapist. Patients may adopt roles within the group such as defiance leader, task leader, emotional leader, and scapegoat leader. As a group leader, the therapist must be aware of these dynamics, as it is their responsibility to manage group anxieties, the boundaries around and within the group, and the safety of the environment.

Therapeutic Factors

Group psychotherapists have identified specific therapeutic factors that account for the improvements observed in group psychotherapy. The practice guidelines developed by the American Group Psychotherapy Association (AGPA) note the following evidence-based therapeutic factors:

• Altruism: Helping other clients in the group fosters a better self-image among participants.
• Catharsis: Members of the group experience and then release strong emotions related to their problems.

• Cohesiveness: The positive emotional connection between clients is considered a core mechanism of action for group psychotherapy and correlates closely with therapeutic alliance. Cohesion seems to facilitate other therapeutic factors and correlates positively with clinical improvement. Cohesion can be enhanced through effective group structure, high-quality verbal interactions during sessions, and the group leader's management of the emotional climate.
  • Intrapersonal cohesion refers to the client's sense of positive emotion about the group.
  • Intergroup cohesion refers to group-as-a-whole cohesion.
  • Interpersonal cohesion refers to specific relationships between clients in the group.

• Corrective experience: The clients re-enact family dynamics in a way that corrects the client's perspective, thoughts, and feelings.
• Development of socializing techniques: Clients learn effective communication techniques in the safety of the group environment.
• Existential factors: Group members accept the consequences of their actions and responsibility for their decisions.
• Imitative behavior: Clients observe other clients working through their problems and, in turn, expand their own skills and awareness.
• Imparting information: The client receives information from the group leader/therapist and the other clients.
• Interpersonal learning—Input: Clients receive input in the form of feedback from other clients.
• Interpersonal learning—Output: Clients experiment with new ways of interacting with other clients.
• Instillation of hope: Clients observe the success of others in the group and become hopeful for themselves.
• Self-understanding: In the group setting, clients gain insight into their experiences, thoughts, emotions, and behaviors.
• Universality: Clients realize that the other clients in the group have similar feelings and problems. 

The AGPA has developed the Core Battery to assist in patient selection, assess therapeutic factors, and track improvements in individual members. Other validated questionnaires include the Therapeutic Factor Inventory and Group Questionnaire.[8]

Therapist as Group Leader Interventions

As a group leader, the therapist serves as a monitor and a model of group norms. Therapists should be open and non-defensive; however, self-disclosure should only facilitate the group. Self-disclosure should be judicious and maintain the focus on the clients. 

According to the practice guidelines developed by the AGPA, a group therapist has 4 primary functions:

• Executive function: The therapist sets the membership, time, subject matter, affective expression, and anxiety boundaries of the group, creating a stable and consistent environment for the clients that fosters group cohesion.

• Caring: The therapist must consider the well-being of the group members, which includes monitoring treatment responses and each client's reactions to therapy. This approach sets the standard for interactions within the group and allows client-client relationships to survive later conflicts.

• Emotional stimulation: The therapist assists clients in identifying and expressing their thoughts and feelings.

• Meaning-Attribution: The therapist assists clients in understanding the dynamics of the group, their fellow clients, and themselves, fostering insight and self-awareness in the client. 

Group Development

Theorists of group psychotherapy have developed both linear and cyclical models to explain the dynamics of group therapy, with the number of stages varying widely from two to nine or more. In their book Basics of Group Psychotherapy (1994), Bernard and Mackenzie suggested that there are 4 assumptions in most models:

• The pattern of development is regular and observable.
• All groups show similar features as they develop.
• Developmental stages are necessarily sequential.
• Interactional complexity increases with time, although there are periods of regression.

The practice guidelines developed by the AGPA suggest the following synthesis of models:

• Forming/preaffiliation: The group seeks guidance from the group leader/therapist and feels anxious regarding the other members and the possibility of improvement. The primary task for members in this phase is to affiliate with the group and engage in meaningful work. Clients do not center themselves as agents of change but rather focus on the therapist and external events. The therapist focuses on education, patient commonalities, and encouraging trust.

• Storming/power and control: The beginning of the emotional engagement, the lack of progress, and the dependency on the group leader or therapist can lead to resentment. This phase often involves questioning the therapist's authority, referred to as the barometric event. The struggle against the therapist often unites the group as members open up to each other. The therapist must remain calm when facing resistance and countertransference, encouraging clients to work on goals, express negative feelings, and connect with one another.

• Norming/intimacy: The group has established connections with one another and recognizes the benefit of collaborative work toward the group's goals. There is a high level of cohesion and denial. The therapist functions more as a facilitator than a leader, balancing support and confrontation.

• Performing/differentiation: Group members recognize and utilize their individual differences to initiate personal change. They feel more at ease with interdependence.

• Adjourning/separation: As the group prepares to conclude, the fear of loss and lack of progress prompt regressions and conflict. The member's appreciation for each other is critical for success at this stage. Members often discuss other losses in their lives and may devalue or idealize the group. Some groups create a termination ritual to contain this loss. 

Group Process

Wilfred Bion identified 3 basic assumptions that can interfere with the group's work. These assumptions indicate that group members are seeking solutions without addressing their problems:

• Dependency: Group members look to the group leader or therapist as a parental figure, hoping to be rescued from their problems.

• Fight or flight: Members hope that the leader directs them into conflict with one another or into avoidance of working through their problems.

• Pairing: The group hopes that an interaction between 2 members (or a subgroup of members) leads to a solution without having to work through their problems.

The therapist works to keep the group on task doing the work without creating a counterproductive degree of anxiety in the members. Anxiety can be reduced with non-work processes. Work processes with a high degree of empirical support are interpersonal feedback and the client-therapist therapeutic alliance.[9]

Cohesion and the group's emotional climate have less empirical support for efficacy. Cohesion refers to emotional connections between group members and is a client-client equivalent to the client-therapist therapeutic alliance. A group with low cohesion tends to work against itself, ultimately leading to its own destruction. A pathological antigroup entirely refuses connection between members. In response to anxieties and tensions, the group splits and subgroups are formed, similar to how clients sometimes fall into specified roles, such as scapegoat, task leader, defiance leader, or difficult patient, within the group. The group leader or therapist notices, observes, interprets, and manages these roles and groups.

Termination

The termination phase guides clients in recognizing the individual changes they have undergone and prepares them for their future transitions. The group leader or therapist must help the group members navigate the loss of client-client relationships and the client-therapist relationship. This process facilitates the clients' traversal of future losses. In closed-ended groups, this loss is processed by the group members simultaneously. In open-ended groups, it occurs as members leave due to achieving their goals or ending participation prematurely. If clients in an open-ended group do not trend towards their goals, the therapist should consider whether the client has formed a dependent attachment to the group that prevents them from working on their problems.

A premature ending may be due to life circumstances or conflicts within the group. The therapist should attempt to facilitate a referral to appropriate mental health care in these cases. Proper handling of these events is essential, as the departure of one client can lead to others leaving due to a contagion effect. When the therapist terminates the group, they should debrief the clients on their care, including possible future availability, reminders regarding confidentiality, and handling of treatment records. In addition, the therapist should facilitate referrals to other mental healthcare professionals.

Issues of Concern

Adverse Outcomes

Adverse outcomes are minimized by careful patient selection and facilitated by the group leader or therapist's management of the sessions. Patients who are unlikely to benefit from group treatment or who otherwise demonstrate contraindications to group treatment should be referred to another provider. Adverse outcomes may result from the behaviors of the group members, as client-client conflict is not uncommon and is not entirely under the control of the therapist. The development of in-group roles, such as scapegoating, may negatively impact the client if they do not have the internal resources to cope with this, for example, socially isolated patients or those in an acute crisis. The therapist should help each group member voice their concerns and limit judging others. Other significant adverse outcomes are negative emotional experiences, treatment failure, and failure to maintain confidentiality. 

Ethics

Group therapy is unique because clients play a role in treating their peers. As a result, confidentiality can be a challenging issue to navigate.[10] The degree of confidentiality required in groups varies based on jurisdiction and state. This topic should be addressed in the preparation stage with individual group members as a part of the informed consent process, and each client should sign a confidentiality agreement. Child and adolescent patients should know what can be disclosed to their parents or guardians. There should be clear and established consequences for a group member who violates the group's confidentiality. 

The group leader or therapist should document objectively, focusing on each client's problems and the therapist's interventions with that client. Documentation about individual group members must not include identifying information about others in the group.

Clinical Significance

Group therapy is an evidence-based intervention for many psychiatric conditions, including but not limited to:

• Depression [11]
• Post-traumatic stress disorder [12][13]
• Anxiety disorders [14]
• Schizophrenia [15]
• Attention-deficit/hyperactivity disorder [16] 
• Obsessive-compulsive disorder [17]
• Personality disorders [18]
• Eating disorders [19]
• Chronic pain [20]
• Nonepileptic seizures [21] 
• Breast cancer [22]
• Liver transplant [23]

Group therapy has demonstrated a low level of evidence for non-suicidal self-injury that did not survive adjustment for publication bias.[24] Increasing evidence suggests that online group therapy is effective in treating various mental health conditions.[25][26]

Enhancing Healthcare Team Outcomes

Some clients may be simultaneously involved in other therapies, such as individual psychotherapy and pharmacotherapy, with various healthcare professionals, including social workers, psychologists, psychiatrists, nurse practitioners, nurses, and rehabilitation therapists. Some treatment programs for more seriously ill patients may require participation in multiple modalities, including occupational therapy, rehabilitation therapy, vocational rehabilitation, and substance use treatment. This comprehensive approach enhances the client's treatment experience, provides essential support, and expands the range of issues that can be addressed. 

• Combined therapy: When a therapist serves as both the group leader and the individual therapist for a client, it fosters a deeper relationship between the therapist and the client. However, this may also raise concerns among group members about potential favoritism, underscoring the need for clear boundaries. Some therapists choose to maintain a combined relationship with all group members, but this can lead to triangulation between the therapist and group members in conflict with each other. There is also the risk of accidentally disclosing information in the group that was shared in individual therapy.

• Conjoined therapy: When a client has a group leader or therapist and a separate individual therapist, regular and high-quality communication between the therapists is essential. Clients may elicit reactions from one therapist that impede the work being done with the other therapist, leading to triangulation. For example, a client may tell the individual therapist about the dynamics in group therapy and use the individual therapist's reaction to justify behaviors in group therapy. Both therapists must obtain releases of information to facilitate this process.[27]

• Pharmacotherapy: Clients often receive pharmacotherapy for their psychiatric symptoms. The therapist should obtain the patient's medication history during intake as germane to treatment and the patient's function within the group, for example, if the patient is sedated during the group or decompensates. If the healthcare professional is also responsible for prescribing medication, they should schedule individual appointments to monitor the efficacy and adverse effects of the drug. As the group therapy concludes, the healthcare professional should arrange ongoing individual appointments or transition care to another healthcare professional to ensure continuity.[28]

Lastly, care coordination is pivotal in ensuring seamless and efficient patient care. Clinicians, advanced practitioners, social workers, occupational therapists, rehabilitation therapists, and other healthcare providers must collaborate to streamline the patient's journey, from diagnosis through treatment and follow-up. This coordination minimizes errors, reduces delays, and enhances patient safety, ultimately leading to improved outcomes and patient-centered care that prioritizes well-being and satisfaction.