Group Therapy

EPPP

psychotherapy groups

• focus on insight & interpersonal change

psychoeducational groups

• focus on skills, education, & structure

  • may include information-sharing, training, and support for coping strategies.

  • skills training w/ little or no interpersonal processing (e.g., anger management or parenting classes) is NOT group therapy

open group

• members join/leave

• examples:

  • hospitals; inpatient

closed group

• same members throughout

• no new members are admitted after the group starts, fostering a stable environment for deeper interpersonal work & cohesion develops

homogeneous group

• members with similar issues (e.g., all adults with depression), fostering quick cohesion and shared understanding

• strengths:

  • safety; cohesion

heterogeneous group

• members with diverse issues (e.g., a mix of individuals with varying psychological concerns), allowing for a broader perspective and richer discussions.

• strength:

  • interpersonal learning

Yalom Group Therapy

• an existential-humanistic approach that emphasizes the "here-and-now" (present moment) within the group, treating it as a social microcosm where members enact their relationship patterns for immediate feedback and growth

• insight alone is NOT the goal

• interpersonal feedback is key

• guided by 11 core therapeutic factors like interpersonal learning and cohesiveness, aiming to improve social skills, self-awareness, & connection

Orientation Stage

• initial/forming phase of Yalom’s Group Therapy where members become acquainted and establish norms.

• members evaluate each other & search for similarities

• members talk to the leader, hesitate to self-disclose

• members seek & give advice

Conflict Stage

• middle/storming phase of Yalom’s Group Therapy

• members test each other & leader

• power struggles or disagreements are common

• advice is replaced with criticism

• leader helps members work thru resistance & ambivalence

Cohesive/Working Stage

• final/performing phase of Yalom’s Group Therapy

• members share openly, trust each other, & are cohesive

• interpersonal learning, self-exploration & problem-solving

• attendance increases

• members show concern when others are absent

Yalom’s Therapeutic Factors: Universality

• “I’m not alone.”

• EPPP clue: relief after hearing similar stories

Yalom’s Therapeutic Factors: Instillation of hope

• seeing others improve → provides optimism about change and recovery.

• EPPP clue: new member encouraged

Yalom’s Therapeutic Factors: Altruism

• helping others helps self

• EPPP clue: giving advice/support

Yalom’s Therapeutic Factors: Interpersonal learning

• feedback about behavior

• EPPP clue: “I didn’t know I came across that way.”

Yalom’s Therapeutic Factors: Group cohesiveness

• sense of belonging

• EPPP clue: attendance increases

Yalom’s Therapeutic Factors: Catharsis

• emotional release

• EPPP clue: crying; expressing feelings

Yalom’s Therapeutic Factors: Imitative behavior

• modeling others

• EPPP clue: learning coping skills

Forming stage of group development

• The initial phase where group members get acquainted, establish norms, and build trust. This stage is crucial for setting the foundation for effective teamwork.

• group leader establishes structure & safety

• members are polite, anxious, & uncertain about norms

Storming stage of group development

• The phase where conflict arises as members assert their opinions and vie for roles, leading to challenges in group dynamics and cohesion.

• group leaders facilitate discussions to manage conflicts and promote collaboration.

• power struggles emerge & members test limits

Norming stage of group development

• The phase where group members establish norms, build relationships, and foster collaboration, leading to greater cohesion and effectiveness.

• trust & cohesion develops

• roles stabilize & trust increases

• members work together

Performing stage of group development

• The phase where the group operates at its highest level of efficiency, focused on achieving goals and producing results. Members are confident in their roles and work collaboratively to tackle challenges.

• group focuses on problem-solving, personal growth, & tasks/productive work

Adjourning stage of group development

• The phase where the group concludes its activities, reflecting on successes and challenges, and members prepare to disband or move on, solidifying learnings and relationships formed during the group's duration.

• group focuses on reflection & dealing with separation

screening & selection for group members

• should be done carefully to ensure a group welfare (safe and effective group environment). This helps maintain a positive dynamic and supports the overall therapeutic process.

• individuals w/ acute psychosis, severe antisocial traits, active substance intoxication, &/or inability to tolerate feedback

confidentiality in group therapy

• Therapist cannot guarantee confidentiality in group settings.

  • not legally liable - if warned members appropriately

• required:

  • clear informed consent

  • explicit discussion of limits

• clarifying & reminding members throughout session

• prevents legal/ethical issues - but is NOT the core safety risk (or most protective measure)

therapist role in group therapy

• Facilitator/leader

  • guides discussion, ensures safety

• Process observer

  • monitors group dynamics

• support/coach

  • encourages engagement

• model

  • demonstrates coping skills & communication

not therapist’s role in group therapy

• authority figure

• evaluator of individual members or group process

• enforcer/disciplinarian (over-step role)

• mediator between members

  • unless facilitation is neutral

• participant (boundary violation)

how therapist handles conflict between members

• facilitate discussion, maintain safety

• encourage members to express feelings constructively

• stay neutral; do not mediate or take sides

• set limits on unsafe/harmful behavior

• document actions & consult supervisor, if needed

• reactive (not preventative measure)

steps in ethical handling of group member conflict

• Acknowledge conflict

• “I see tension here; let’s discuss it safely”

• Encourage self-resolution

  • Members describe feelings, reflect on impact

• Focus on group process

  • Explore dynamics, communication styles, reactions

• Set behavioral limits if necessary

  • Stop harmful comments or unsafe behavior

• Maintain confidentiality

  • Conflict resolution occurs within the group, not by reporting outside

dual relationship between group members ignored

• ethical boundary violation due to conflict of interest or pre-existing relationships

• ignoring it can create coercion, favoritism, or exploitation

to avoid violation from dual relationship between members

• screen members before group

• address potential issues openly

• consider separate group or supervision

failure to manage hostility

• can lead to escalation of conflict and disrupt group dynamics. It undermines trust and safety within the group.

• can include threats, mocking, intimidation, or personal attacks (physical or emotional)

• ethical principle violated: duty to protect participants & maintain safe environment

correct handling for managing hostility

• stop behavior immediately

• facilitate constructive discussion

• set group rules & limits

not screening members

• ethical principle violated:

  • Competence & Risk Management

• includes accepting members without evaluating suitability (e.g., acute psychosis, severe antisocial traits, cognitive impairments)

  • it can compromise group safety, cohesion, or therapy effectiveness

• single most protective practice

poor role clarification

• ethical principle violated:

  • Boundary & Dual-Role

• occurs when roles (facilitator, observer, model) are not clearly defined

  • Members unclear what therapist can/cannot do

  • Confusion about whether therapist evaluates, mediates, or disciplines

no informed consent

• ethical principle violated:

  • Autonomy

• occurs when participants are not fully aware of their rights, risks, and the nature of the therapy, impacting their ability to make informed decisions.

  • full confidentiality cannot be guaranteed

avoid breach of confidentiality

• explicitly discuss limits at start

• include in written consent

• remind periodically

psychotherapy groups

• process-oriented

• purpose:

  • emotional insight, interpersonal patterns, psychological change

• features:

  • here-and-now interactions

  • group process is the treatment

  • therapist facilitates, does not “teach” (no curriculum)

• all “typical therapy groups fall under this category.

• all are emotional-processing & clinician-led

• groups do NOT involve the therapist teaching, training, or support alone

• therapist role: facilitator

psychoeducational groups

• purpose is education & teaching coping skills

• features:

  • structured; information-focused; CAN include discussion but education is its primary purpose

• therapist role: teacher

• examples: parenting groups, anxiety education groups, illness management groups

Skills training groups

• purpose: teach specific skills; focus is on behavior change (NOT insight)

• features:

  • highly structured; practice-based; often manualized

• therapist role:coach

• examples: DBT skills group; social skills group; anger management groups; assertiveness training groups.

• the group is the format, not the treatment

  • is not group/process therapy

support groups

• purpose: emotional support; shared experience; normalization

• features:

  • peer-driven; minimal therapist role (or only facilitative); focus on mutual support NOT change; limited process-focused

• members should NOT expect deep psychological change

• does not have treatment plan

• therapist role: minimal

• examples: grief group; caregiver support group

task/problem-solving groups

• purpose: accomplish task or goal

• features:

  • goal-oriented; time-limited; outcome-focused

• often consultative, not therapy

• therapist role:leader

• examples: treatment planning teams; school intervention teams

self-help/mutual-aid groups

• peer-led support

• features:

  • no professional leader; share experiences; no formal treatment

• therapist role:none

• examples: AA; NA

❌ Skills training ≠ psychotherapy

• Teaching coping skills (breathing, DBT skills, parenting skills) by itself is not therapy

• Why

  • No emotional processing

  • No insight work

  • No therapeutic relationship focus

• example: a group that teaches relaxation techniques each week is not psychotherapy

❌ Structured curriculum = NOT process therapy

• If every session follows a script or lesson plan, it’s instructional, not therapeutic

• Why

  • Process therapy = spontaneous interaction + emotional exploration

  • Curriculum = teaching content

• example: “session 3 covers communication skills from a manual → not process group

❌ Support ≠ treatment

• Feeling supported does not automatically mean therapy is happening

• Why

  • Therapy requires intentional psychological intervention

  • Support groups focus on sharing, validation, normalization

• example: A cancer support group sharing experiences → not psychotherapy

❌ Therapist teaching = psychoeducation

• When the therapist’s role is mainly lecturing or instructing, it’s education

• Why

  • Therapy focuses on change through interaction, not lessons

• example: “therapist explains anxiety symptoms each session → psychoeducation

❌ Peer-led ≠ therapy

• If no trained clinician is facilitating, it’s not therapy

• Why

  • Therapy requires clinical judgment and responsibility

• example; AA-style peer group w/o therapist → Not psychotherapy

Psychodynamic Groups

• Goal: insight → symptom change

• insight-oriented psychotherapy

  • Focus on unconscious processes

  • Past relationships replayed in present group

  • Group interaction is the treatment

• Core goal

  • Increase insight

  • Resolve interpersonal patterns

  • Reduce symptoms via understanding

• does not involve teaching active behavioral techniques, manuals or structured tasks, psychoeducation, or focused on giving advice

Here-and-Now Focus

• 1 of the core concepts of psychodynamic groups

• Emphasis on current interactions in the group

• How members relate to each other reflects outside relationships

Transference

• 1 of the core concepts of psychodynamic groups

• Members project feelings from past relationships onto: therapist or other group members

• Example

  • Treating leader like a critical parent

Countertransference

• 1 of the core concepts of psychodynamic groups

• Therapist’s emotional reactions to members

  • Must be recognized and managed

Resistance

• 1 of the core concepts of psychodynamic groups

• Avoidance of painful insight or change

• Defensiveness, silence, intellectualizing, joking

Interpretation

• 1 of the core concepts of psychodynamic groups

• Primary intervention

  • Therapist links past → present → group behavior

  • Makes unconscious material conscious

Universality

• 1 of the core concepts of psychodynamic groups

• Yalom factor

  • Realizing “I’m not alone”

  • Reduces shame and isolation

Therapist’s Role in Psychodynamic Groups

• Facilitator of insight

• Observes patterns

• Interprets meaning

• Encourages interaction between members (not advice-giving)

• Does NOT involve teaching, giving solutions, or heavily attempting to control the group

Mechanism of Change

for Psychodynamic Group Therapy

• Insight through interpersonal experience

  • Corrective emotional experiences

  • Increased self-awareness

  • Understanding relational patterns

• EPPP cue: “The group becomes a social microcosm”

Screening for Psychodynamic Group Therapy

• important b/c it can evoke strong emotions, uses minimal structure, & relies on insight & affect tolerance

• appropriate for: individuals with adequate ego strength, ability to tolerate anxiety & affect, capacity for self-reflection, some psychological mindedness, & stable reality testing

• evaluate for:

  • reality testing (distinguish between internal perceptions and external reality)

  • impulse control

  • affect tolerance (can experience emotions without decompensating/panic)

  • motivation

• Not “one and done”

  • it is conducted throughout length of group to monitor for decompensation & remove member if risk escalates

Risk Management Requirements or Psychodynamic Group Therapy

• informed consent (include nature of group & emotional intensity it evokes)

• ongoing assessment

• handling hostility & confidentiality management

Interpersonal Process Groups

• psychodynamic / process-oriented

• features:

  • “here-and-now” interactions

  • emphasis in insight, transference, and interpersonal relationships

  • minimal structure

• does NOT include advice-giving or skills training

Goals of Interpersonal/IPT Groups

• address role transitions (e.g., retirement, divorce)

• improve interpersonal functions

• address grief (process emotions, adjust to life changes, and reduce isolation)

• address conflict (identify dysfunctional patterns)

Therapist role in Interpersonal Process Groups

• Facilitator

• Interprets patterns

• Encourages reflection

• Does NOT teach skills

Screening for Interpersonal Process Groups

• Good ego strength

• Affect tolerance

• Reality testing

• Ability to self-reflect

• contraindications: active psychosis; severe impulsivity; severe cognitive impairment; acute crisis

Risks associated with Interpersonal Process Groups

• Emotional flooding

• Scapegoating

• Acting out

• Group dynamics

  • which can lead to misunderstandings and conflicts

CBT Groups

• Features:

  • Structured

  • Time-limited

  • Goal-focused

  • Symptom reduction

• Focus

  • Thoughts → feelings → behaviors

  • Skills practice (homework)

Therapist role in CBT Groups

• Active

• Teacher/coach

• Provides structure

Screening for CBT Groups

• individuals motivation for skills

• cognitive capacity

• basic emotion regulation

• Contraindications:

  • severe cognitive impairment; active psychosis; severe dissociation

Goals for CBT Groups

• change distorted thinking → change behavior/emotion

• teach coping skills & problem-solving skills

Goals for Humanistic / Experiential / Gestalt Groups

• increase self-awareness, self-expression, authenticity, & personal growth through interpersonal relationships and experiential activities.

Humanistic / Experiential / Gestalt Groups

• Features

  • Emotional expression

  • Authenticity

  • Experiential techniques (chair work, role-play)

• Focus

  • Self-awareness / insight

  • Personal growth

  • Emotional experiencing

• Risks

  • emotional flooding

  • boundary confusion

• It is NOT a structured curriculum, is NOT focused on skills training, & therapist is NOT neutral

Therapist role in Humanistic / Experiential / Gestalt Groups

• Facilitator

• Models genuineness

• Encourages expression

Family Systems–Based Groups

• Focus on interpersonal relationships and dynamics within families, NOT focused on individuals

• if you only treat the symptom w/o addressing the system, the problem will persist or shift to another family member

• System > symptom

  • interaction patterns are more important than the individual’s symptom (e.g., anxiety, acting out, substance use)

• System = family roles, boundaries, communication patterns, alliances, power dynamics

• semi-structured

• does NOT teach skills

Interactional cycles:

• aspect of Family Systems–Based Groups

• Circular Causality:

  • Interactions are not linear (A causes B), but reciprocal, where everyone contributes to maintaining the pattern.

• Homeostasis:

  • Systems resist change and act to maintain their typical, even if dysfunctional, interactional patterns.

• Common Patterns:

  • Pursuer-Distancer: One member (pursuer) demands connection, causing the other (distancer) to withdraw → increases the pursuer's intensity.

  • Attack-Defend: High-conflict interaction where one member's criticism is met with defensiveness → escalating the conflict.

  • Triangulation: Two people in conflict pull in a third person to stabilize their relationship or reduce tension.

• Breaking the Cycle:

  • Therapy involves changing the "rules" of the system (second-order change), improving boundaries, and increasing emotional regulation (differentiation of self)

Therapist’s role in Family Systems–Based Groups

• Active director

• Reframes

• Maintains neutrality

• No taking sides, NO doing individual therapy within group, & NO ignoring power dynamics

Trauma Processing Groups

• Features:

  • Focus on trauma processing

  • NOT skills-only

  • Emotionally intense

  • Revisiting trauma content

  • Semi-structured

Therapist’s role in Trauma Processing Groups

• Highly active

• Regulates affect

• Maintains safety

Screening for Trauma Processing Groups

• most critical of all the group therapies

• Stabilization first

• Grounding skills present

• No active dissociation

• Contraindications:

  • drug use; unstable PTSD; severe dissociation; recent trauma without stabilization

• Risks

  • Retraumatization

  • Emotional overwhelm

  • Symptom worsening

The greater the level of emotional intensity the group evokes

• the more critical screening group members is

  • critical for trauma processing groups & interpersonal groups (in that order)

  • still important for CBT, Humanistic, & Family Systems

less structured groups

• more responsibility for therapist to screen, monitor members, & get consent

  • higher risk of emotional decompensation, boundary violations, escalated conflict, confidentiality breaches, & ethical/liability

groups that skills are taught in

• CBT

• psychoeducation

groups that require insight

• psychodynamic

• humanistic

• experimental

• Gestalt

EPPP trick questions on group therapy:

“most appropriate group,” “primary role of therapist,” “most relevant ethical issue”

• hinge on screening, structure, & therapist’s role

Premature Termination in Group Therapy

• often due to conflict; unmet needs, dissatisfaction, anxiety, & external life events

• 10-35% during 1st 12-20 sessions

Cohesion & Effectiveness on Group Therapy

• when it is increased → attendance, participation, adherence to norms, & outcomes all increase

Altruism: Group Therapy

• members help each other → fosters self-worth