Continuing Education Activity

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.

Objectives:

• Describe the elements of group therapy that can increase the chance of patients benefiting from the treatment process.
• Review the presence and management of issues of patient confidentiality during group therapy sessions.
• Summarize the management of internal issues that disrupt group therapy sessions.
• Explain the importance of interprofessional collaborative efforts when providing treatment in a group setting.

Introduction

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).[1][2][3][4]

Function

Yalom Therapeutic Factors

It is vital to patient success that providers understand the mechanisms that exist in group therapy. These factors are:

1. Universality: Patients realize that others exist who share similar thoughts, feelings, and issues.
2. Altruism: Patients can improve their self-concept by assisting other patients.
3. Instillation of hope: Patients benefit from witnessing the success of other group members and can envision themselves following a similar path.
4. Imparting information: Patients gain knowledge and information from both the group members and the provider.
5. Corrective recapitulation of primary family experience: Patients can benefit from the opportunity to properly recreate family dynamics in a controlled environment.
6. Development of socialization techniques: Patients learn effective and proper ways to interact with others.
7. Imitate behavior:  Patients gain new insight and understanding through the observation of other group members.
8. Cohesiveness: Patients experience feelings of support, trust, and belonging to one another.
9. Existential factors: Patients realize that they are responsible for their life decisions.
10. Catharsis: Patients share personal experiences from both the past and present.
11. 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.
12. Self-understanding: Patients understand the covert factors influencing their behavior and emotions.

Goals

• The process goals of group therapy are to facilitate patients' growth in comfort and function within the group.
• 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.[6]

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.[7]

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.[8]

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.[9]

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.[2][9][10][11][12]

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 their 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.[13]

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.[14]

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 patients’ 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.[15]

Support Groups

Support groups can be used to help patients who have already begun receiving treatment to 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.[16]

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.

1. 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. 
2. Storming stage: In this stage, patients will now be comfortable sharing intimate details with one another. 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. 
3. 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.
4. 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. 
5. 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.[17]

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.

Issues of Concern

Patient Confidentiality

Similar to individual treatment, the provider or group leader in group therapy sessions are bound to the laws of confidentiality concerning patients' medical history, diagnoses, and other personal information. The other group members, however, are not bound to these same laws and face no legal consequences for sharing information from sessions. As a result, individual patient confidentiality can be difficult to maintain, especially in larger groups where leaders have less control over what information gets shared within the group.

The ability to share personal information can play a positive role in the treatment process. Some patients may feel uneasy sharing certain details for fear of who may repeat them, which can cause harm to patients' mental wellbeing as they struggle to contribute while maintaining their confidentiality. To reduce this tension, providers should adopt a set of confidentiality/sharing guidelines that the group agrees to and discuss with members the limitations of confidentiality before the first session.[18]

Clinical Significance

Effectiveness

Research has shown that group therapy is an effective method to treat a myriad of psychiatric and behavioral disorders. Patients often report a reduction in symptoms after receiving group therapy treatment. Additionally, group therapy is found to affect patients positively through Yalom Therapeutic Factors. These factors do reduce symptoms of diagnoses while also providing patients with beneficial skills to learn, develop, and live with their symptoms. As long as patients are subject to proper screening before group therapy sessions, they will receive benefits.[1][10][19]

Concurrent Treatment

Although group therapy is an effective method of treatment in itself, providers may also choose to incorporate other treatment methods to treat patients further. 

• Conjoint therapy: When performed conjointly, the provider treating the patient in the group differs from the provider treating the patient individually. Doing so provides patients with different therapeutic settings, allowing them to learn as an individual and apply those teachings in a group setting.
• Combined therapy, on the other hand, occurs when the provider treating in the group setting also treats the patient individually. This method of concurrent treatment allows providers to thoroughly assess patients and provide individual coaching, which is applicable in the group setting. When placing a patient into a group, special care should be used to ensure the patient gets put into a group homogenous for symptoms and diagnosis.[20]

Cost-efficiency  

Group therapy provides a cost-efficient method of treatment, as fewer trained professionals are required to provide treatment to a larger number of patients. A reduction in cost can increase the accessibility of therapy, as costs are often covered by insurance plans.[1]

Flexibility

Treatment in a group setting allows providers to be more flexible with their sessions. Doing so can increase attendance to therapy sessions since providers can schedule sessions during after work and after school hours. Additionally, the inclusion of multiple sessions throughout the day allows providers to treat a larger volume of patients throughout the day, further reducing wait times in high-volume areas.[1]

Training Opportunities

The group format can be used as an avenue to train medical students, residents, and other healthcare professionals by allowing them to serve as co-therapists. The provider can oversee the less experienced professionals as they work with patients, effectively creating on-the-job coaching; this can be especially useful in low resource areas where access to trained professionals is limited.[1]

Other Issues

Other Issues

Conflict

Conflict is a natural and expected aspect of group therapy sessions. Many conflicts may not be obvious to the group members, and it is the responsibility of the provider to bring these covert conflicts to the members’ attention. The provider is not required to solve the conflict; however, he or she must make an informed decision on how to deal with the conflict based on the interest of the group. It may be worthwhile to address the conflict, as there is an opportunity for the group to learn. 

Members’ responses to conflict can be complex and unpredictable. When conflict arises, providers should use the last five to ten minutes of the session to speak with patients individually and allow them to voice their concerns.

Patients Who Ramble

Occasionally, a patient may continue to talk for an unnecessary length of time. It is essential to address this patient and see what he or she hopes to gain when doing so. If the patient is unsure as to why they are dominating the conversation, the provider should use this opportunity to teach the patient how to express his or her thoughts and feelings better.

Lack of Engagement

It is the provider’s responsibility to ensure members are alert and attentive during group sessions. When members seem disengaged, the provider should interject and see why members are losing interest. The inclusion of interactive activities can help members to be more engaged in the group discussion.[11]

Patients’ Limits

Providers are encouraged to push their patients to engage with the sessions; however, it is crucial to be aware of a patient’s individual limits. If the provider’s initial request for the patient to continue engaging meets with resistance, then the provider should respect this wish. Providers should remain patient, understanding, and empathetic with their patients and continually encourage without forcing patients to act against their will.[9]

Enhancing Healthcare Team Outcomes

Pharmacotherapy and Group Therapy

Occasionally, patients receiving group therapy will also benefit from the inclusion of pharmacotherapy. In situations where the provider prescribing the medication differs from the provider providing treatment, proper communication between the two parties is vital to patient success. A thorough report of the patient and his or her reaction and benefits from the medication must be shared with the provider treating with group therapy. Mutual respect for one another and the well-being of the patient are required to prevent adverse reactions and ensure the patient receives the highest quality of medical care. Additionally, putting less of a value on either of the two treatment processes can negatively impact patients, so the therapist should always follow proper inclusion and management of both treatment processes.[21]

When pharmacotherapy is part of the patient's therapy, it is prudent to have a qualified pharmacist examine the patient's medication record, checking for proper dosing, potential drug interactions, and inform the other members of the healthcare team of any red flags.

Social workers can play an important auxiliary role to providers during group therapy sessions. The social worker's presence as a layperson voicing their thoughts and feelings can help facilitate group interaction and reduce members’ resistance to contributing. Also, social workers can assist patients in attempting to reintegrate into their “normal” lives by answering patient’s questions concerning work, relationships, and other lifestyle changes.[22]

An interprofessional team approach can benefit participants in group therapy, where information is shared among various disciplines leading to improved patient outcomes, so long as appropriate privacy considerations are maintained at all times. [Level 5]

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses trained in psychiatric and behavioral sciences can take on the role of group therapy leader and host group therapy sessions. Their responsibilities reflect those of other healthcare providers, and supervision is not required when a properly trained nurse is leading group therapy.[23]