The Lost Art of Group Therapy: Best Bang for Your Buck

We are social creatures, and as social creatures, our need to congregate are important to our survival. The negative psychological impact of isolation was globally recognized and observed in the face of the COVID-19 pandemic – decreasing social connection and interaction – leading to a collective risk of mental health issues due to removing this basic human need. And with the massive uprise in depression and anxiety in the past couple of years since the pandemic started, increasing accessibility and affordability for effective mental health care (without burning out our providers in the process) is of upmost importance.  The upsurge of online mental health companies coming out of the woodwork over the past years have helped on a large scale – offering low-cost therapy through the convenience of your digital devices – leading companies like Betterhelp and Talkspace. While these companies offer affordable and accessible mental health care – and CAN be helpful to the consumers. One thing that is not often exposed is the mental wellbeing of the providers working in these companies. The mental health field is notoriously known for being high stress, low pay. Companies that offer affordable care often do so at the expense of hardworking therapists’ wellbeing and mental health – with large caseloads, low pay, and high stress. It’s hard to be an effective therapist if you are seeing 30, 40, 50 or even 60 patients a week! You would be running on fumes.  I know this feeling well. I lived this life for more than 5 years. And I can talk a lot more about this topic and what I believe is best for my fellow therapists – but I’ll save this for another day.

There is a better solution – for the therapists and patients.

The answer: group therapy.

As a private practice owner, I am well aware of my limitations. I can only help so many people and do so much by seeing people individually for therapy. There’s only one of me. Yet, I know there’s a huge need out there – and many who cannot afford the full cost of therapy. And with limited slots for pro-bono and sliding scale fees, the struggle is real. In my efforts to make mental health services more available, affordable and accessible to people in need, while ensuring that I am well within my bandwidth to offer the highest quality of care, it’s important to educate and advocate for the lost art of group therapy.

WHAT IS GROUP THERAPY?

Group therapy is a type of psychotherapy where several people attend the same session led by one or more qualified therapists. Using various evidence-based modalities, group therapy can treat a range of problems including relationship difficulties, personality issues, grief, trauma, substance abuse, anxiety, and depression.

The history of group therapy began in Boston, MA in 1906, when a physician, Dr. J.H. Pratt, provided group instruction for patients with tuberculosis (TB), with the initial intent of providing support to those unable to afford institutional assistance. While conducting these groups he noted “beneficial emotional side effects,” which served as some of the earliest notes on the efficacy of group therapy.

The concept of group therapy gained even more popularity when proven especially useful in treating veterans after World War II. As a result, the US Army released a report in 1944 commending the positive effects of group therapy. It was later developed and pioneered by several important figures in the field of psychology – to name a few, Kurt Lewin, Irvin D. Yalom and Carl Rogers. Their work on group therapy continues to be very influential worldwide.

Group sizes vary depending on the type of therapy, which may include anywhere from 5 to 15 people. Research, however, on the effectiveness of group therapy generally recommend 6 (minimum) to 12 (maximum) individuals in a group with at least one therapist.

TYPES OF GROUP THERAPY

Psychoeducational. The primary focus of these groups is to educate and inform individuals about a relevant mental health-related topic or issue. Think of this as similar to attending a class, workshop or lecture. It’s a pre-planned curriculum that is very informational.

Skill-based.  This form of group is a structured course where the therapist can adapt the teaching of skills based on the needs of the individuals in the group. Skills are learned and practiced such as coping mechanisms, CBT tools, mindfulness tools, and many others.

Support Group. Just as the name suggests, this model provides support and care for the members while teaching them interpersonal skills through group discussion, shared experiences, and collaborative problem-solving.

Process-oriented. Process groups are intentionally unstructured to allow for members to reveal the organic patterns they go through when trying to build and maintain relationships. The focus here is an interpersonal process that is less on the “there-and-then” and more on the here-and-now. For example, rather than focusing on your childhood, you talk about the reactions you are having to your fellow group member or therapist(s). The processing of an experience, emotion, or problem in the here-and-now is key to the impact of this type of group. The purpose of the group is to find out more about who they are and what they would like to change in their own personal lives and relationship with others. It heavily relies on the interpersonal relationship and group cohesion. A typical process group will run for about 6 months (sometimes shorter, such as 12 weeks which are just as effective).

Keep in mind that groups are fluid – and therapists can integrate and overlap many of the concepts based on the dynamic, needs and goals of the group. So it’s not uncommon that a therapist will shift from one model to another in a single group session.

THE ENGINE FOR CHANGE

Groups have been shown to be a powerful way for individuals to learn about themselves and how they connect with the world around them. Developing close and intimate relationships with complete strangers can seem daunting, but when group members are able to move pass that emotional barrier and develop trusting relationships, experiences can be profoundly healing and transformative.

Here are some common benefits of group therapy are:

• Groups can act as a support network. In individual therapy, the therapeutic alliance between therapist and patient is the most important element for effective treatment. In group therapy, it’s the rapport amongst the members of the group – the interaction between the group members provides the engine for change, while the therapist’s responsibility is to facilitate that experience.
• Group provides a sense of belonging. There’s an assurance that you are not alone. It can be a relief to hear others discuss what they’re going through, and realize you’re not alone. Even if your problems are different, you are connected by a common goal: to get better.
• The opportunity to give and receive support. Both of these concepts are important in therapy for individual growth and learning.
• Multiple perspectives and accountability. By seeing how other people tackle problems and make positive changes, you can discover a whole range of strategies for facing your own concerns. Also, other members of the group will often help you come up with specific ideas for improving a difficult situation or life challenge, and hold you accountable along the way.
• Self-awareness and insight. Regularly talking and listening to others also helps you put your own problems into perspective, with the added benefit of understanding how you impact others.
• Cost-Effective. Group therapy is generally less expensive than individual psychotherapy. A primary reason for this is because it essentially splits the cost of the therapist’s time across multiple members. Further, this allows many providers to offer sliding scale and pro bono services for those demonstrating financial need.

Additional benefits identified by Dr. Irvin Yalom – who made a name for himself, as a professor of psychiatry at Stanford University, as a psychotherapist and as an author – is listed below, extracted from the definitive text on group therapy titled, The Theory and Practice of Group Psychotherapy which is still used by millions of therapists today.

Yalom’s Eleven Therapeutic Effects in Group Therapy:

1. The instillation of hope creates a feeling of optimism.
2. Universality helps group members realize that they are not alone in their impulses, problems, and other issues.
3. Imparting information helps to educate and empower people with knowledge pertaining to their specific psychological situation.
4. Altruism allows clients to gain a sense of value and significance by helping other group members.
5. Corrective recapitulation provides for the resolution of family and childhood events within the safety of the group family.
6. Socializing techniques promote social development, tolerance, empathy, and other interpersonal skills.
7. Through imitative behavior group members learn to adopt the coping strategies and perspectives of other group members.
8. Interpersonal learning teaches clients how to develop supportive interpersonal relationships.
9. Group cohesiveness gives members a sense of acceptance, belonging, value, and security.
10. Catharsis releases suppressed emotions and promotes healing by disclosing information to group members.
11. Existential factors incorporate learning how to just exist as part of something larger than oneself. This factor brings a client into the awareness that life will continue on, with pain, death, sadness, regret, and joy. By living existentially, clients learn how to accept these conditions without escaping from them. Instead, they learn how to live with them and through them.

POTENTIAL RISKS

Although there are many benefits to group therapy, there are also some risks to point out. Here are some common risks and disadvantages:

1. Members dropping out. If members are inconsistent with attendance or unwilling to fully participate, treatment outcomes will be compromised.
2. Less personalized than individual therapy. Of course, group therapy will take away some of your spotlight and the level of intervention will not be as highly focused or intense for any single person as it would be in individual therapy.
3. Fixed group meeting times. Group typically meet at specific times and there is less opportunity to personalize the meeting times to fit your personal schedule.
4. Limits to confidentiality. While the group members are instructed that the information shared in the group are to be held private and confidential and only to be shared with group members during the session, the potential for a breach of privacy is greater than in individual therapy.
5. Social anxiety. Individuals who have a fear of public speaking may find the group setting uncomfortable. And those who struggle interpersonally may find themselves in continued conflict with other group members.

As with most things in life, there are no rewards without some level of risks involved. 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 and anxiety. Partly as a result of these research, demand for group therapy is up.  And with the increasing prevalence in mental health conditions, the need for more affordable access to qualified providers is changing the way mental health is being offered. Group therapy is a fantastic alternative to individual therapy – and the benefits absolutely outweighs the risks. Nonetheless, I offer some useful ways that you can take to make the most out of group therapy.

10 TIPS TO MAKE THE MOST OUT OF GROUP THERAPY

Therapy is always a collaborative process – whether that’s group therapy, individual therapy, family therapy or couple’s therapy. Thus, the success of any therapy heavily depends on each of you – the participant. Here are ways to make the most out of group and mitigate any potential risks.

1. Set your intention to be open. By entering the group with an intention to connect with other group members, you open yourself up with the courage to be transparent, curious, and self-reflective. Make efforts to think out loud – no one can read your mind. The process of practicing your articulation of personal thoughts, feelings, and judgments as they emerge during the group is an important skill for real life. Let people know when you feel discontent. If you want to add your voice, interject or interrupt. If the group does not feel as alive as you want, say so. If you want more, be real and vulnerable with someone in the room. If you don’t trust someone, address your feelings with some urgency. If something is going unacknowledged, point it out. If the therapist said something you don’t like, speak up. You will become more connected to yourself and others as you become more engaged in the process of group therapy. Honesty really is the best policy here.
2. Respect and protect group boundaries. Maintain confidentiality of content in the group and the anonymity of group members. Arrive on time. Stay for the duration of the group. Attend each group session and if you have to be absent, let the group know in advance. Keep all interactions between group members to the group room, and if that boundary is breached, bring the interaction back to the group. Promptly admit to any violation to group boundaries. Let others know how you feel about their behaviors. The group will feel safer when you respect and attend to boundaries. And for online group therapy: find a safe, quiet space dedicated for the session. Limit distractions. Invest in a white noise machine so others can’t hear you.
3. Practice authentic connection. Share your inner subjective experience — how others affect you, and how you connect (or don’t connect) to what is being shared. Look for commonalities with others in the group. Notice how you connect with other’s stories, feelings, and goals. Allow yourself to dislike someone or a behavior. At first, you may feel that you do not fit in with other group members — you may see yourself as superior, inferior, or just incompatible based on any number of demographic or other dimensions. Letting others know of how your perception of these differences is getting in the way of your trusting the group can be the first step to building authentic connection.
4. Be curious about yourself and others. Notice when you choose to be silent. Notice when you choose to speak your mind. Notice what you choose to edit your thoughts. Be curious about your own behaviors – the seen and unseen – what’s happening internally and how you choose to exhibit yourself externally to others. Ask questions about others and invite others’ curiosity about you. If you find yourself curious about someone in the group, ask questions. The person can always decline to answer. Above all, bring your curiosity about yourself. Ask for feedback. Ask if something you do is off-putting or generates closeness. Welcome and invite others to provide you with their unfiltered experience of you.
5. Be vulnerable and take some emotional risks. Early in the group, it may be hard to avoid wanting to be liked or trying not to offend. However, you will need to take risks to learn about yourself in relationships and your impact on others. Your willingness to look unembellished, illogical, vulnerable, and unresolved will evolve as the group matures. Your authentic feelings about a topic or person are more useful to the individual (and the group as a whole) than your approval and/or solving their problem.
6. Bring any topic. Share your suffering, your pain, your dilemmas, your worries, your failures with group members and ask them to confront and hold you until you find the courage and clarity to make changes. Also bring your joys and successes. Explore your love and your hate. Actively bring what you need to talk about when you need to talk about it regardless of what others might be going through.
7. Examine your choices. Bring up life decisions with the group early on in your decision-making process — including thoughts about possibly leaving the group. Ask the group for help in identifying the problem, looking at your motivations, identifying your options, and evaluating how they might work out for you. What are you trying to fix and how? The process will highlight some of your issues around identifying your needs, identifying your intentions, and how your choices undermine your own thriving.
8. Trust the process. By sharing whatever arises inside of you, at a given moment you are surrendering to the process, giving others a chance to understand you, and facilitating a process through which you will learn to trust. But don’t wait for the process to take you to where you need to go. What you are willing to share will evolve over time. You will have to initiate self-disclosure, correct mis-representations of yourself, and divulge secrets to present yourself more authentically.
9. Take care of your relationships in the group. Keep in mind that while an outside issue may be a useful starting point in the group, the greatest learning will happen when thoughts, feelings, and judgments come up about group and during group. We call this being in the “here and now” or “being present in the room.” Stay in the room, as much as possible. Ask yourself what you can or can’t connect with, whom you identify with, and whom you have written off. At first, it may feel difficult to bring up feelings in the heat of the moment. So as in any long-term relationship, come back to leftover and unwanted feelings with the intention of getting closer.
10. Build your tribe and make a better family for yourself. The group becomes a representation of your social interactions and relationships outside of group. The group is designed to bring up unconscious issues so that you can learn to notice and let go of old ways of treating yourself and others. Most likely, some of these ways of being will come up early in the group. You have to get stuck in group so you can learn to get unstuck. Be curious about the intensity of your reaction. If your emotions are very intense and last more than several minutes, you are in transference. While it may feel overwhelming to feel yourself so exposed, remind yourself that this is when you will learn the most about the unconscious patterns you bring to relationships. You have the opportunity over the next few months to create corrective experiences with this group. In short, make it your group.

THE AIM OF GROUP THERAPY

When it comes to mental health services in general, individual therapy is definitely the more popular route. And it makes complete sense – as mental health can be a massively personal subject, it may seem intimidating to add more people to the room! But – this also decreases the availability of therapists. Group therapy has its place in the world of mental health. Just because your treatment is shared with others doesn’t mean it’s less effective.

Just like individual therapy, applying what is learned in group therapy to life outside of therapy is the main goal. This means individuals are able to make behavioral corrections, implement the interpersonal skills they learned to new and existing relationships, and utilize the preventative measures and coping skills when necessary.

The hope of writing this blog is to open your eyes to an interesting and effective approach that – though somewhat harder to find than individual therapy – is well worth the effort to seek out.

Currently, I offer Online Group Therapy for all California residents in my practice. To learn more, please reach out here.

 

About the Author

Albert Nguyen is a licensed psychotherapist in private practice. He specializes in providing an integrative and eclectic approach to mental health care that includes personal self-care, anxiety and depression, and peak performance in children, teens and adults. Reach out for more information on how he can be of service to you here.