When Noelle L. Lefforge, PhD, ABPP, first tried to shift her treatment model from individual to primarily group psychotherapy, she wondered why potential patients weren’t signing up. Then she discovered that the administrative staff were telling callers that all the individual therapy slots were full, but they could assign them to group therapy. The unspoken assumption? That group therapy is second best.
That’s simply not true, said Lefforge, president-elect of APA’s Division 49 (Society of Group Psychology and Group Psychotherapy) and president of the division’s Group Specialty Council, which advocates for group psychotherapy as a specialty area. “Over the past decade or so, there has been a lot of research coming out that clearly shows that, for most of the things people present to services for, group therapy is as effective—if not more so—than individual therapy,” said Lefforge, who directs the Professional Psychology Clinic at the University of Denver. “When done well, there’s the added benefit of efficiency: serving more folks with fewer clinicians in less time.”
In short, group therapy could be part of the solution to the national mental health crisis. Respondents to APA’s 2021 Covid-19 Practitioner Survey reported that demand for services was surging. Yet almost two thirds of respondents lacked the capacity to take on new patients. And more than two thirds said their waiting lists were even longer than they had been in 2020.
[Related: Gary Burlingame studies outcomes and group therapy]
If you’re interested in introducing group psychotherapy into your practice, use these tips from Lefforge and other experts:
Get training. Psychologists sometimes assume that group therapy is a “generalist skill,” said Havana, Florida, private practitioner Joshua Gross, PhD, ABPP, past president of Division 49. Or they misunderstand what group psychotherapy is all about. “Just getting five people into a room doesn’t necessarily mean group therapy,” said Gross. Most psychologists don’t get a lot of training in group psychotherapy, he said, noting that surveys show that counseling and clinical psychology programs don’t include much group work. The result? Trainees are often put into situations they are not prepared for. “I’ve talked to a lot of people who tried doing group therapy and say, ‘I had a bad experience, and I’m never going to do that again,’” said Gross. “It’s because people are getting on the freeway too soon.”
To build those group therapy skills, Gross and others suggest taking advantage of the resources and training opportunities offered by Division 49 and the American Group Psychotherapy Association. Review the education and training standards, draft practice guidelines, and other resources that were part of Division 49’s successful effort to get APA’s Commission for the Recognition of Specialties and Subspecialties in Professional Psychology to recognize group psychology and group psychotherapy as a specialty in 2018. And, although it’s not required before offering group psychotherapy, psychologists can also get credentialed in group psychotherapy via the American Board of Group Psychology or the multidisciplinary International Board for Certification of Group Psychotherapists. Once a clinician is providing group psychotherapy, peer consultation and supervision can also be helpful.
Set the group’s purpose and format. There are two predominant kinds of group psychotherapy, said Les R. Greene, PhD, coeditor of Core Principles of Group Psychotherapy: An Integrated Theory, Research, and Practice Training Manual (Routledge, 2020), which serves as a curriculum for the International Board for Certification of Group Psychotherapists credential. In heterogeneous groups, “folks with a variety of symptoms explore their interpersonal relationships via the social microcosm of the group,” said Greene, who serves on the clinical faculty at the Yale School of Medicine and maintains a private practice in Hamden, Connecticut. In homogeneous groups, now the most popular format, individuals come together to explore their shared problem, whether it’s trauma, eating disorders, or substance misuse.
For Decatur, Georgia, practitioner Christina Camp, PhD, bringing together groups of patients facing similar challenges makes the most sense because it allows them to learn from each other’s experiences. Since 2015, she has offered group therapy for Black women, which she calls the Sister Circle Experience, as a way of helping them dismantle the strong Black woman ideology that leads to women supporting others at the expense of their own well-being. During the pandemic, she began a second group therapy program focused on the challenges Black women face dating in a virtual world. The groups help participants overcome feelings of isolation in confronting particular challenges and help them develop new coping skills, said Camp, founder and chief executive officer of Camp Psychological and Consulting Services.
“You’re in collaboration with women who might have addressed your problem in the past, and having that example could be helpful in giving you hope and perspective,” said Camp, adding that while the 12-week Sister Circle groups have an overall focus, participants are free to address any topic. “Other women might not have reached where you are now and are still struggling with what you used to struggle with, which gives you a deeper sense of your capacity and a sense of where you’ve been versus where you’ve landed.”
Choose the right cofacilitator. Managing the dynamics in group therapy can be complicated, and it can be useful to have a cofacilitator, said Lefforge. Sometimes group leaders, especially trainees, may not have a say in whom they’re paired with. “Pairing supervisors and trainees is very common and often essential to training,” she pointed out. In that case, it’s important to recognize the power dynamics involved and carefully consider roles and expectations, she said. If possible, choose a cofacilitator you already know and whose theoretical orientation and style are compatible with your own so that conflicts don’t arise.
Lefforge allots time before and after sessions to discuss goals and progress with her cofacilitator, debrief about what happened in a group, and share feedback. “Plus, if someone gets up urgently and leaves the room, it’s nice to have two facilitators so one can attend to that situation while the other stays with the group,” she said.
That said, having a cofacilitator can bring its own complications, Greene noted. “It’s like being in a marriage,” he said. “You want to speak the same language.” While having someone else’s perspective can be helpful, he said, involving another facilitator can add compatibility problems, whether personal or professional, to an already complex milieu.
Screen and prepare participants. Group therapy isn’t appropriate for everyone, said Lefforge. People experiencing acute psychosis won’t do well in groups, for example, and those with antisocial personality disorder can derail groups unless the group specifically targets that disorder. When recruiting participants, said Lefforge, “it’s helpful to have heterogeneity in terms of identities but homogeneity in terms of presenting problems or degree of functioning.” To ensure a good fit, Lefforge screens potential participants in an individual session.
She also addresses any hesitancies about group therapy. “People say, ‘How will it help me to hear other people’s problems?’” said Lefforge. “Or they say, ‘I couldn’t possibly talk about myself in a group.’” Such concerns are so common that Lefforge has developed a guide for administrative staff and other therapists that addresses each concern to help them normalize anxieties about group therapy and emphasize the format’s effectiveness. For those concerned about baring their souls to strangers, Lefforge explains that participants only share what they’re comfortable sharing. For those skeptical about the value of hearing other people’s problems, Lefforge points to the therapeutic value of connecting with and helping others.
These individual sessions should also serve as orientations that explain what group therapy is all about. To create a sense of safety and cohesion, explain how group therapy works, what they will be asked to do, and what your role as facilitator is.
Psychologists should set ground rules during these individual sessions with participants before they join the group, then reinforce those rules when the group comes together. “You want to give people the lay of the land to see if they’re okay with that,” said Greene. “You give some orientation about what the norms are—that you are going to encourage people to listen actively and carefully to what each person has to say, offer constructive feedback, and not blame or attack each other.”
Repair ruptures. So-called ruptures—hurtful interactions between a participant and other group members, between the facilitator and the group, or between cofacilitators—are an inevitable part of the experience, said Cheri L. Marmarosh, PhD, an associate professor of clinical psychology at the George Washington University. And repairing these ruptures helps patients grow, she said (International Journal of Group Psychotherapy, Vol. 71, No. 2, 2021). “Ruptures need to be welcomed and addressed, not avoided,” she said. “Growth really does come when patients take risks, learn that people are not perfect, and identify their contribution to relationship struggles.” Group therapy, she explained, helps participants learn skills to live in a world where people say and do hurtful things. They learn that people can be confronted and learn to change and that people can be forgiven, for instance. “Group therapy facilitates true intimacy where there is healthy conflict and compassion for self and others,” she said.
When a participant responds to a rupture in a direct, confrontational way, said Marmarosh, the facilitator should take that seriously and help the group explore the hurt and angry feelings and then explore the underlying issues that can contribute to them, such as racism, privilege, or sexism. However, some participants may respond to ruptures in more subtle ways, such as withdrawing from discussions, changing the topic, or skipping sessions. Facilitators can invite these participants to talk about their experience of the group, said Marmarosh, adding that some facilitators ask participants to complete feedback surveys after each session so the facilitators can be more aware of ruptures during the group sessions.
Be aware of special challenges with virtual groups. As online group therapy has become increasingly common following the shift to telehealth prompted by the pandemic, practitioners need to be aware of additional challenges. Confidentiality, already a big concern for group members, becomes more difficult when group therapy takes place online, said Haim Weinberg, PhD, who codirects the Sacramento Center for Psychotherapy (American Journal of Psychotherapy, Vol. 74, No. 2, 2021). Participants need specific instructions about how to ensure privacy and avoid interruptions, whether that’s locking the door to a room or sitting in a parked car, said Weinberg.
Also, group cohesion seems to develop more slowly online, said Weinberg. “All we see are squares, not the full body,” he points out. “Participants do not sense the entity of togetherness we usually sense when we sit together in the same room.” Small gestures aren’t visible, and direct eye contact isn’t possible. “In my office, I simply move my gaze from one person to another, sending the message that I see them and hold them in my gaze,” he said. “If I try to do it online, people just see my eyes moving without understanding that I’m looking at them.” One solution is to verbalize more than you would in-person, saying a participant’s name and telling that person you are looking at them, he said.
Whether online or in-person, group therapy has the potential to ameliorate the global mental health crisis, say practitioners. For Greene, the hope is that group psychotherapy becomes much more popular in the United States. “In our society, we are sort of an individualistic culture and people by and large are going to say they want individual therapy,” said Greene, a past president of the American Group Psychotherapy Association. “In other cultures, people are much more ready to say they want to work with a group of like-minded people.”