Reasons for Suggesting Group Psychotherapy to Patients

Research has demonstrated that both individual (1, 2) and group therapy (3) can help patients live more fulfilling and happier lives, although studies have also suggested that whichever modality the therapist prefers shows more efficacy. In examining 67 studies that compared formats, Burlingame et al. (4) found no difference between formats for “rates of treatment acceptance, dropout, remission, and improvement.”

Group therapy may have special utility in current society, as societies worldwide seem to be splitting into us-versus-them camps. One great asset of therapy groups, in which people are offered the opportunity to be honest with one another in a safe setting, is that participants typically come to find that people are ultimately more alike than different, regardless of color, religion, or political stance.

As psychodynamic theory has become less inward and more relational in focus, this premise that people are more alike than different increasingly applies. Intersubjectivity, humanistic theory, relational therapies, and object relations theory all emphasize various aspects of human relatedness as key to diagnosis and healing. “Object relations theory begins by assuming that people are born seeking and needing relationships. . . . The degree to which those behaviors fail to accomplish that goal has to do with members’ needs to feel safe and protect themselves” (5). It could be argued that the most prevalent psychiatric problems today are object-relational disorders. This is particularly problematic because “human beings are herd animals. We begin in small groups—our families—and live, work, and play in various groups” (6). I wrote this article during a pandemic, at a time when our natural groups have been severely disrupted.

History of Group Therapy

Many cite Joseph H. Pratt (7) as the first group therapist, because he assembled his 15 tuberculosis patients into groups at the Massachusetts General Hospital, where they talked about their illnesses and problems and agreed on a set of guidelines defining how the groups would operate. Pratt reported that patients who participated in these groups responded better to their tuberculosis treatment than those who did not. But those groups, which engaged in activities such as lectures and outdoor meetings, bear little resemblance to modern psychotherapy groups.

For all practical purposes, modern group psychotherapy traces its origins to the military during World War II, when the number of patients far exceeded the number of providers. Field doctors, medics, and nurses were instructed to see patients in groups. Although these caretakers had no formal training in group therapy or group process, it quickly became evident to them that something powerful happened when soldiers were seen in groups. The whole effect of group treatment was much larger than the sum of individual outcomes. Since that time, practitioners have been trying to harness the power of groups to help patients most effectively.

Despite immediate public acceptance of group therapy in the 1950s and 1960s, as evidenced by the plethora of “sensitivity groups” that developed during the decades after the war (cf. the Esalen Institute and the 1969 movie Bob and Carol and Ted and Alice), the influential psychoanalytic community pushed back against the idea. Analysts, who relied on therapist opacity to foster transference, were wary of the group setting, where therapist opaqueness would be much less possible. Perhaps because of this early conflict, group therapy has struggled through the years to be viewed as equal to individual therapy in effectiveness (8). “Given the fantasied blissful relationship of the maternal dyad that persists in our culture as the ideal symbiosis, it is always a challenge to present the patient with group therapy as a full-fledged treatment model on a true par with individual treatment” (9).

Similarities and Differences in How Group and Individual Therapy Work

The most consistent finding in the outcomes literature (10) is that the quality of the relationship between the therapist and the patient has more impact on outcome than any other variable. This is true in both group and individual therapy, although Holmes and Kivlighan (11) argue that individual therapy is more self focused, and group therapy is more relationship focused. In this context, group therapy makes greater use of the power of relationships, not only with the therapist but also with peers.

A patient in an individual therapy session has a markedly different experience than a patient in a therapy group. In the former, there is a clear power differential, whereas in the latter, there are peers. In the former, trust must be formed with one professional, whereas in the latter, trust must be formed with multiple others who are not sworn to professional roles and indeed have agreed to share their feelings freely. Although quite different, the two settings are both powerful.

Patient’s defenses appear and are considered differently in the two settings. For example, one common and powerful defense readily available for exploration in group therapy is projective identification (which Shay [12] has suggested renaming as “projective recruitment”).

Example of Projective Identification at Work

Tom entered group therapy to deal with problems in his marriage. He felt the problem was entirely his supercritical, harsh, “mean” wife. Indeed, as he entered the group, he presented a picture of a very difficult, unhappy, and sadistic wife. The women in the group immediately liked Tom. He was a man who spoke openly of his feelings, even occasionally shedding a tear.

Over the course of several months, however, the women became increasingly unhappy with Tom, often angrily confronting him. One evening Tom said, “Oh my god, you women sound like my wife!”

The group leader said, “And it only took you a few months to train them.” Although stunned, Tom took that observation seriously. He asked the women what he had done to turn them from liking him to disliking him. The women carefully and poignantly pointed out that they were very concerned for him and had offered many suggestions to help with his marital problems, each of which he refused to follow. They each described how frustrating this was for them and how exasperated they became with him.

Over the ensuing months, Tom did some wonderful work uncovering his ability to “turn women into” a facsimile of his mother, who was critical of him and who had depression. One day, the group therapist received a letter from Tom’s wife with a note asking that the letter be read in the group. Although this was an unusual request, the therapist felt it was appropriate on this occasion. The letter essentially said, “I want to thank the group for returning my husband to me.”

In this situation, group therapy uniquely offered the opportunity for Tom to experience how he affected and influenced others and to hear their feedback. Several of the women in the group also stated that they had begun to question how much they might be contributing to interactions with their partners that they had previously seen as solely the responsibility of the “other.”

Another difference between the two settings is that, in individual therapy, patients can reveal shameful feelings and experiences in the relative safety of a one-to-one relationship with a professional, whereas in group therapy, members risk more public exposure and shame (13).

Example of Universality in Group

Joe, a young Roman Catholic man, was in a mixed group that included a Roman Catholic priest. Joe was shy and often mute during sessions, although he clearly seemed to be attentive. At one meeting, Joe atypically asked for time to speak. He said that he had been wanting to talk about something for months but had felt too embarrassed and ashamed, especially with Father Ben in the group.

The group supported Joe to talk, and with hesitation and tears, Joe confessed that he had been masturbating. The group’s reaction was, “That’s it?” Several participants in the group then spoke of their masturbation with varying degrees of shame. Joe was astonished, having felt that he alone practiced masturbation. He looked to Father Ben, whom he looked up to greatly and said, “I’m so sorry I’ve disappointed you.” Father Ben, a remarkable man in his own right, said simply, “Joe, the only sin is if you don’t enjoy it.” Father Ben added, “I probably shouldn’t tell you this, but I have a great many parishioners who share that they masturbate.”

As the group began to stand to leave, another group member, Jill, spoke up, with tears in her eyes, “Joe, I owe you a lot. I’ve been so ashamed of masturbating for so long. Only now I see that it’s just part of being human.” Several other members echoed that sentiment.

This example highlights some of the unique powers of groups. Not only did members experience universality, but Joe also experienced a moment of altruism. For one of the few times in his life, he felt he had enabled another just by being himself. Although the experience of shame certainly occurs in all therapy, other participants’ transparency and what Yalom and Leszcz (14) refer to as universality are uniquely available in group therapy.

Individual and Group Therapy Together

One particularly powerful treatment option is for a patient to participate in individual and group therapy simultaneously (9, 15). This dual treatment can occur with the same therapist in both modalities or with different therapists. If the same therapist conducts both modalities, this arrangement presents the rich opportunity to view the patient in both the dyad and the interpersonal group setting. In this case, the therapist must determine and negotiate a contract with the patient for how information that appears in one setting will be handled in the other.

Having different therapists conduct the individual and group therapy presents the advantage of another set of eyes and ears on the patient. At the same time, the arrangement creates the added complexity of a relationship between the two therapists, which requires extra communication.

Advantages and Disadvantages of Group Therapy

In evaluating new patients, rather than asking, “Would this patient profit from group psychotherapy?” instead, I ask, “Is there any reason this person would not profit from group psychotherapy?”

This approach is predicated on the conviction that perhaps the most powerful healing agent available to our patients is the capacity to develop and sustain healthy relationships. This conviction is supported by the 80-year longitudinal Harvard Study of Adult Development (16), which consistently has found that happiness comes from healthier personal relationships rather than from wealth or accomplishment. The study also found that people with good relationships are both physically and psychologically healthier than those without such relationships. In a review of 148 studies of the importance of relationships on physical health, Holt-Lunstad et al. (17) confirmed that finding, stating that unhealthy relationships or a lack of relationships have as much impact on health as smoking and alcohol consumption.

The therapeutic relationship is a powerful component of all psychotherapy. Group therapy adds multiple relationships, the element of peer transferences, expanded feedback opportunities, and the opportunity to take risks in practicing new relationship skills in real time.

Poor Candidates for Group Therapy

Despite my enthusiasm for group therapy, there are instances where group is not the treatment of choice (6). When individuals refuse to join a group or are extremely anxious about the prospect of joining a group, they should be seen individually, at least at first. The strong aversion to joining a group will likely be an important point of curiosity for the therapist and for examination in individual sessions. Often, such patients can later join a therapy group very productively. If forced to join too early, however, they often drop out of the group.

Similarly, individuals whose work or life schedule does not allow them to regularly meet with the group are not candidates for group therapy. Airline pilots or crew, for example, are not good group therapy candidates. Their lack of regular attendance would be a source of frustration to everyone.

Although some clinicians have had success treating patients with extremely poor object relatedness (18), some individuals are unlikely to remain in the group long enough to establish an alliance with the other members. These are usually individuals with such insecure attachments that it is unlikely that they can accept the group or be accepted by group members. Sometimes these individuals can join a group after successful individual treatment.

Individuals with poor impulse control are not good candidates for group therapy, and individuals coming to therapy in immediate crisis should not be asked to put that crisis aside to meet several strangers in a group. However, sometimes such individuals can be placed in a specific crisis group (e.g., a bereavement group); individuals who undergo a crisis often find their therapy group an immense source of comfort and strength.

Types of Groups

It is not enough to simply recommend group therapy to a patient or to a supervisee asking for treatment suggestions for a patient. There are many kinds of groups that respond to different issues. Fundamentally, there are two types of groups: those formed heterogeneously and those formed homogeneously. Both types of therapy groups can be conducted as time-limited or ongoing groups, and both types can be conducted from a variety of theoretical bases (e.g., cognitive-behavioral therapy, dialectical behavioral therapy, interpersonal psychotherapy, or psychodynamic therapy).

Homogeneously formed groups (e.g., women’s groups, men’s group, elderly persons’ groups, bereavement groups, substance abuse groups) can be formed around demographic or diagnostic categories. Typically, these groups cohere and get to work more quickly, because members immediately feel a sense of universality and commonality (i.e., “These people understand my situation”). Typically, over the course of such a group, the members notice, “You know, we are actually quite different from one another.”

Heterogeneously formed groups model society itself, with different kinds of people making up the group. Often individuals will question why they have been placed in this group with these people. If the groups mature well, the trajectory of heterogeneously formed groups is quite different from homogeneously formed groups. Members who felt so different from one another at first begin to notice that, ultimately, members are more alike than different. Recognizing fundamental similarities is one of the most powerful elements in bridging the us-versus-them divide.

Conclusions

Research (19–21) has shown that psychotherapy is beneficial for most people. Some people prefer the individual modality, and some prefer the group modality. Shechtman and Kiezel (8) have suggested that some people prefer individual therapy because they get the complete attention of the therapist, prefer the intimate relationship with the therapist, trust that the therapist will maintain their confidentiality, and do not fear the therapist’s criticism. Those authors also suggest that others prefer group therapy because they seek feedback, want to experience universality, find listening to others interesting, like that they can sit back and not always be the focus, and find the group format more easily affordable. For some individuals, either modality, or a combination of both modalities, is the optimal treatment, but that is a topic for another article.

In my experience, most people seeking psychotherapy seek to learn how to love and be loved better. Few come to therapy using these words, but upon close examination, that is what they desire. The interpersonal nature of group psychotherapy provides an opportunity to explore how to invite, allow, and sustain more intimacy in one’s life.