Group therapy is the treatment of multiple patients at once by one or more healthcare providers. It can be used to treat a variety of conditions including but not limited to emotional trauma, anxiety, depression, post-traumatic stress disorder (PTSD), and attention deficit hyperactivity disorder (ADHD). This activity outlines the principles of group therapy and explains the role of the interprofessional team in evaluating, treating, and improving care for patients who undergo group therapy.
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including art therapy, cognitive behavioral therapy, or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process are explicitly utilized as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.
As the need for behavioral intervention and long-term psychiatric care is steadily rising, alternative methods of treatment must be employed by physicians and healthcare teams to meet this increasing demand. Group therapy provides a solution to this problem by allowing for the treatment of multiple individuals simultaneously. Doing so allows healthcare providers to reduce wait times and increase accessibility. This approach is especially necessary for rural and low-income areas where clinics are often understaffed and have a high volume of patients. Furthermore, group therapy can be used to treat a multitude of conditions including, but not limited to, emotional trauma, anxiety, depression, post-traumatic stress disorder (PTSD), and attention deficit hyperactivity disorder (ADHD).[rx][rx][rx][rx]
Therapeutic principles
Irvin Yalom proposed a number of therapeutic factors (originally termed curative factors but renamed therapeutic factors in the 5th edition of The Theory and Practice of Group Psychotherapy (1st edition 1970, 5th edition 2005).
- Universality
- The recognition of shared experiences and feelings among group members and that these may be widespread or universal human concerns, serves to remove a group member’s sense of isolation, validate their experiences, and raise self-esteem
- Altruism
- The group is a place where members can help each other, and the experience of being able to give something to another person can lift the member’s self esteem and help develop more adaptive coping styles and interpersonal skills.
- Instillation of hope
- In a mixed group that has members at various stages of development or recovery, a member can be inspired and encouraged by another member who has overcome the problems with which they are still struggling.
- Imparting information
- While this is not strictly speaking a psychotherapeutic process, members often report that it has been very helpful to learn factual information from other members in the group. For example, about their treatment or about access to services.
- Corrective recapitulation of the primary family experience
- Members often unconsciously identify the group therapist and other group members with their own parents and siblings in a process that is a form of transference specific to group psychotherapy. The therapist’s interpretations can help group members gain understanding of the impact of childhood experiences on their personality, and they may learn to avoid unconsciously repeating unhelpful past interactive patterns in present-day relationships.
- Development of socializing techniques
- The group setting provides a safe and supportive environment for members to take risks by extending their repertoire of interpersonal behaviour and improving their social skills
- Imitative behaviour
- One way in which group members can develop social skills is through a modeling process, observing and imitating the therapist and other group members. For example, sharing personal feelings, showing concern, and supporting others.[rx]
- Cohesiveness
- It has been suggested[rx] that this is the primary therapeutic factor from which all others flow. Humans are herd animals with an instinctive need to belong to groups, and personal development can only take place in an interpersonal context. A cohesive group is one in which all members feel a sense of belonging, acceptance, and validation.
- Existential factors
- Learning that one has to take responsibility for one’s own life and the consequences of one’s decisions.
- Catharsis
- Catharsis is the experience of relief from emotional distress through the free and uninhibited expression of emotion. When members tell their story to a supportive audience, they can obtain relief from chronic feelings of shame and guilt.
- Interpersonal learning
- Group members achieve a greater level of self-awareness through the process of interacting with others in the group, who give feedback on the member’s behaviour and impact on others.
- Self-understanding
- This factor overlaps with interpersonal learning but refers to the achievement of greater levels of insight into the genesis of one’s problems and the unconscious motivations that underlie one’s behaviour.
Types of Group Therapy
Group therapy can be categorized into different types depending on the mental health condition it is intended to treat as well as the clinical method used during the therapy. The most common types of group therapy include:
- Cognitive behavioral groups, which center on identifying and changing inaccurate or distorted thinking patterns, emotional responses, and behaviors
- Interpersonal groups, which focus on interpersonal relationships and social interactions, including how much support you have from others and the impact these relationships have on mental health
- Psychoeducational groups, which focus on educating clients about their disorders and ways of coping; often based on the principles of cognitive behavior therapy (CBT)
- Skills development groups, which focus on improving social skills in people with mental disorders or developmental disabilities
- Support groups, which provide a wide range of benefits for people with a variety of mental health conditions as well as their loved ones
Groups can be as small as three or four, but group therapy sessions often involve around eight to 12 people (although it is possible to have more participants). The group typically meets once or twice each week, or more, for an hour or two.1
Group therapy meetings may either be open or closed. New participants are welcome to join open sessions at any time. Only a core group of members are invited to participate in closed sessions.
Group Therapy Techniques
What does a typical group therapy session look like? In many cases, the group will meet in a room where the chairs are arranged in a large circle so that members can see every other person in the group.
A session might begin with members of the group introducing themselves and sharing why they are in group therapy. Members might also share their experiences and progress since the last meeting.
The precise manner in which the session is conducted, and any group therapy activities, depend largely on the goals of the group and the therapist’s style.
Some therapists might encourage a more free-form style of dialogue, where each member participates as they see fit. Other therapists have a specific plan for each session that might include having participants practice new skills with other members of the group.
Group Therapy Activities
Common group therapy activities can include:
- Icebreaker activities that help group members get to know one another
- Gratitude activities, such as mapping different aspects of their life that they are thankful for
- Sharing activities, where group members ask one another questions
- Expressive writing activities to explore experiences and emotions connected to those events
- Goal visualization activities to help people set goals and make a plan to accomplish them
What Group Therapy Can Help With
Group therapy is used to treat a wide variety of conditions, including:
- Attention-deficit/hyperactivity disorder (ADHD)
- Depression2
- Eating disorders
- Generalized anxiety disorder
- Panic disorder
- Phobias
- Post-traumatic stress disorder (PTSD)
- Substance use disorder
In addition to mental health conditions, CBT-based group therapy has been found to help people cope with:
- Anger management
- Chronic pain
- Chronic illness
- Chronic stress5
- Divorce
- Domestic violence
- Grief and loss
- Weight management
After analyzing self-reports from people who have been involved in the process, Irvin D. Yalom outlines the key therapeutic principles of group therapy in “The Theory and Practice of Group Psychotherapy.”6
- Altruism: Group members can share their strengths and help others in the group, which can boost self-esteem and confidence.
- Catharsis: Sharing feelings and experiences with a group of people can help relieve pain, guilt, or stress.
- The corrective recapitulation of the primary family group: The therapy group is much like a family in some ways. Within the group, each member can explore how childhood experiences contributed to personality and behaviors. They can also learn to avoid behaviors that are destructive or unhelpful in real life.
- Development of socialization techniques: The group setting is a great place to practice new behaviors. The setting is safe and supportive, allowing group members to experiment without the fear of failure.
- Existential factors: While working within a group offers support and guidance, group therapy helps members realize that they are responsible for their own lives, actions, and choices.
- Group cohesiveness: Because the group is united in a common goal, members gain a sense of belonging and acceptance.
- Imparting information: Group members can help each other by sharing information.
- Imitative behavior: Individuals can model the behavior of other members of the group or observe and imitate the behavior of the therapist.
- Instills hope: The group contains members at different stages of the treatment process. Seeing people who are coping or recovering gives hope to those at the beginning of the process.
- Interpersonal learning: By interacting with other people and receiving feedback from the group and the therapist, members of the group can gain a greater understanding of themselves.
- Universality: Being part of a group of people who have the same experiences helps people see that what they are going through is universal and that they are not alone.
Function
Yalom Therapeutic Factors
It is vital to patient success that providers understand the mechanisms that exist in group therapy. These factors are:
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Universality: Patients realize that others exist who share similar thoughts, feelings, and issues.
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Altruism: Patients can improve their self-concept by assisting other patients.
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Instillation of hope: Patients benefit from witnessing the success of other group members and can envision themselves following a similar path.
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Imparting information: Patients gain knowledge and information from both the group members and the provider.
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Corrective recapitulation of primary family experience: Patients can benefit from the opportunity to properly recreate family dynamics in a controlled environment.
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Development of socialization techniques: Patients learn effective and proper ways to interact with others.
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Imitate behavior: Patients gain new insight and understanding through the observation of other group members.
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Cohesiveness: Patients experience feelings of support, trust, and belonging to one another.
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Existential factors: Patients realize that they are responsible for their life decisions.
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Catharsis: Patients share personal experiences from both the past and present.
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Interpersonal learning: Patients gain an understanding of their interpersonal impact via feedback from other members as well as create an environment for one another to learn.
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Self-understanding: Patients understand the covert factors influencing their behavior and emotions.
Goals
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The process goals of group therapy are to facilitate patients’ growth in comfort and function within the group.
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The outcome goals of group therapy are applied to the patient’s life outside of the group and include behavior corrections, development of interpersonal and relationship skills, education, the installation of preventative measures and coping skills, and an eventual return to normal functioning within society.[5]
Selection of Patients
When deciding which patients will benefit the most from group therapy, providers utilize the therapeutic alliance. The more the provider and patient agree on the goals and tasks of therapy as well as the stronger the relationship they share, the more likely the patient will have success in group therapy.[rx]
An additional selection method providers can use to gauge group therapy viability is the NEO-Five-Factor Inventory. This measure of personality suggests that those who score high on extraversion (openness) and conscientiousness (hard-working) dimensions are more suited for group therapy, while those who score high levels of neuroticism (emotionally reactive) are less suitable for group therapy.[rx]
Group therapy will be useful for the treatment of patients who exhibit interpersonal difficulties and pathology; patients who lack self-awareness; patients who are action-oriented; patients who suffer from isolation and require the stimulation group interaction provides, and those who will benefit from interacting with peers who can both challenge and support them.[rx]
Special attention must be paid to ensure patients unfit for group therapy do not get selected as their inclusion can have deleterious effects on both the patient and the group. Specific exclusion criteria are limited to patients who are unable to participate in the major activities of the group due to logistical, cognitive, or interpersonal factors. Additionally, patients in acute distress or actively suicidal should not be considered for group therapy and instead need independent management. Outside of these factors, the exclusion criteria for patients should be more relative than absolute. As a result, a patient unfit for one group due to conflicting personality traits may fit in a group that has similar traits to the patient.
Different Stages of Treatment
It is necessary to include patients at different stages of treatment to help facilitate individual recovery. By comparing themselves to other patients further along in the recovery process, patients can start to imagine themselves in a similar position. Additionally, seeing patients worse off than them but still contributing to the group can provide motivation, keeping patients committed to the treatment process.[rx]
Identical or Similar Conditions
Group therapy sessions should include members suffering from similar conditions. Doing so allows patients to realize that their symptoms are not exclusive to them, and others share similar feelings. This feeling of universality can create a sense of community within the group and facilitate the treatment process by fostering feelings of acceptance and belonging.
Structuring groups with members diagnosed with similar conditions also allow group members to learn from and instruct one another. Interpersonal learning allows members to gain new perspectives on their conditions and learn successful ways to cope. Additionally, members who typically experience social fear as a result of their symptoms become more comfortable with exposure to social situations.[rx][rx][rx][rx][rx]
In addition to adhering to the principles of group therapy, providers should use different styles of group therapy based on the diagnosis and needs of the patients.
Psychoeducational Groups
Psychoeducational groups are useful for educating patients about their diagnosis as well as the inclinations and consequences associated with these inclinations. These groups also serve to encourage patients to stay committed to their treatment plans. Additionally, psychoeducational groups teach patients to avoid maladaptive behaviors while also instilling positive behavior change.
When organizing a psychoeducational group, the provider should follow a highly structured plan and develop a curriculum. Sessions should last anywhere from 15 to 90 minutes, and chairs should be organized in a horseshoe or circle configuration where the provider is the focus.
During psychoeducational group sessions, the provider will act as an educator. Teaching should be performed actively as passive note-taking is inefficient and allows patients to escape the focus of the group. To ensure patient engagement, providers must foster a culture of interaction by creating an environment where patients feel comfortable speaking. Additionally, when leading a session, the provider should incorporate different learning styles, such as visual learning, auditory presentations, and hands-on activities, to accommodate the wide variety of methods in which patients learn.[rx]
Skills Development Groups
Skills development groups are useful for patients whose diagnosis has prevented the adequate skill development necessary to function in everyday life. This style of group therapy also focuses on coping methods, emotional control, and socialization techniques. By focusing on specific skills that patients lack, providers can help prepare patients for the treatment process and give them the tools to recover.
Providers running skills development groups should base the content of the group on the needs of that group’s patients. As a result, the actual material discussed will vary significantly from group to group. Skills development sessions should range from 45 to 90 minutes in length and be organized in either a horseshoe or circle configuration. These groups should be limited to 8 to 10 patients as it is highly interactive and provides ample time for each patient to practice the skills taught. The provider themselves must have mastery of the skills they plan to teach so they can effectively teach them to the group.[rx]
Cognitive-Behavioral Groups
Cognitive-Behavioral groups are useful for changing patients’ learned behaviors by altering their beliefs and perceptions. These groups can also change patients’ perceptions of themselves, turning negative thoughts of being different and unlovable into more positive thoughts. This change in thought process can be extremely freeing to patients as they learn to live with their issues rather than being ruled by them.
The content discussed in these groups will also vary greatly. The provider should focus on beliefs, coping skills, thought processes, or behavior based on the needs of the patients. The orientation of the room for this particular style of the group should be a circle as the horseshoe orientation can interfere with the cohesiveness of this group. Sessions should last anywhere from 60 to 90 minutes.
Similar to psychoeducational groups, the provider of cognitive-behavioral groups should take an active role during the session; however, discretion must be used to ensure the provider does not over-participate negating the members’ ability to interact. It is vital to the patient’s success that the provider acts as a guide and let the group work through most issues themselves.
Since the discussions in these sessions are focused on thought and behavior modification, patients may feel uncomfortable and try to resist these changes. Providers must be prepared for this resistance and gently guide the members through their issues with just the right amount of empathy and firmness.[rx]
Support Groups
Support groups can be used to help patients who have already begun receiving treatment maintain their new behaviors and reinforce their new belief systems and thought processes. These groups also focus on the management of symptoms of day-to-day life. During sessions, patients usually discuss recent problems and how they dealt with them.
Support group sessions should last anywhere from 45 to 90 minutes. Sessions should also be conducted in a circular configuration.
Unlike psychoeducational and cognitive-behavioral groups, the provider of support groups is less directive and should act only as a facilitator. As such, the provider should assist patients in developing connections with one another and emphasizing similarities between patients. The provider’s main contribution to the group should be limited to positive reinforcement and to bring to attention appropriate interactions patients exhibit.[rx]
Group Development
Providers should be aware of the different stages of group development as a transition through each stage indicates group growth and change. Transitioning through all five stages is necessary for patients to benefit from group therapy.
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Forming stage: During the forming stage, patients will exhibit feelings of anxiety, distrust, and uncertainty concerning the group. There will be a high level of dependence on the provider, and actual group interaction will be low during this stage. Providers should use this opportunity to educate the group and establish cohesiveness by discussing goals and expectations.
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Storming stage: In this stage, patients will now be comfortable sharing intimate details. Additionally, the formation of subgroups may occur as patients establish a hierarchy. Internal conflict will predominantly occur in this stage of group development. The provider should aim to resolve disruptive conflict and encourage patients to develop strong and personal relationships with one another. The reinforcement of goals and the purpose of the group can help bring patients together.
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Norming stage: After conflict resolution has occurred, the group will enter the norming stage. While in the norming stage, patients’ commitment to the group and its goals will strengthen, and group cohesiveness will increase. Patients will take on much of the leadership work initially performed by the provider. As such, the provider should take a less active role in the discussion and instead facilitate discussion and provide insights. The return of conflict is a sign of regression to a previous developmental stage, and the provider should intervene to bring the group back to this stage.
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Performing stage: Upon entering the performing stage, the group has greatly matured relative to the earlier stages. Provider intervention is low, as the group functions almost entirely on its own. Patients are aware of each other’s strengths and weaknesses and can help each other develop and grow.
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Adjourning stage: The final stage of group development is the adjourning stage, which signifies that group therapy is coming to an end. Patients may experience feelings of sadness and anxiety as they will no longer be attending sessions. During this stage, the provider should assist patients in voicing their feelings and facilitate discussion of closing topics. Additionally, the provider should help patients plan for life outside of group therapy and assist patients in saying goodbye. Improper management of a farewell process can negatively impact patients and hurt the progress they have made.[rx]
Length of Treatment
The duration of group therapy treatment is highly individualized and subject to a high degree of variation. Patients should receive therapy until they achieve relief from their symptoms and can begin to develop a normal life with strong relationships and a sense of belonging; this can take anywhere from weeks to months or even years to occur. To facilitate patient improvement, providers should structure the ending of therapy processes. By establishing a set end date during treatment, the provider can prepare the patient for an eventual departure with the patient working towards the achievement of his or her goals until that date.
Benefits of Group Therapy
There are several advantages of group therapy.
Support, Safety and Encouragement
Group therapy allows people to receive the support and encouragement of the other members of the group. People participating in the group can see that others are going through the same thing, which can help them feel less alone. The setting allows people to practice behaviors and actions within the safety and security of the group.
Role Modeling
Group members can serve as role models for other members of the group. By observing someone successfully coping with a problem, other members of the group can see that there is hope for recovery. As each person progresses, they can, in turn, serve as a role model and support figure for others. This can help foster feelings of success and accomplishment.
Insight on Social Skills
By working with a group, the therapist can see first-hand how each person responds to other people and behaves in social situations. Using this information, the therapist can provide valuable feedback to each client.
Affordability
Group therapy is often very affordable. Instead of focusing on just one client at a time, the therapist can devote their time to a much larger group of people, which reduces the cost for participants.
While costs vary depending on a variety of factors, estimates suggest that group therapy costs, on average, one-half to one-third less than individual therapy.
References
