Group Psychotherapy as a Specialty: An Inconvenient Truth
Abstract
Group psychology and group psychotherapy (GPGP) are distinctive, effective practices that meet an important need. In 2018, the American Psychological Association recognized GPGP as a specialty, thus setting standards for education and training in the field. Although there is a need for high-quality group psychotherapy, practitioners often lack standardized training, thus posing a risk to patients. Adoption of these standards by practice settings and training programs is essential for expanding the availability of quality group therapy. An understanding of how the specialty became recognized and of the specific criteria for its practice (i.e., public need, diversity, distinctiveness, advanced scientific and theoretical preparation, structures and models of education and training, effectiveness, quality improvement, guidelines for delivery, and provider identification and evaluation) are essential for expanding the availability of high-quality group psychotherapy. Such understanding also informs how training programs can align with standards. This article provides a foundation of understanding and details implications of group psychotherapy’s establishment as a specialty. The benefits of high-quality group psychotherapy are far-reaching, whereas the risks of inadequate practice loom large.
Highlights
Group psychotherapy offers promise in addressing major mental health service shortages throughout the United States, particularly by providing access to efficacious care for diverse populations.
The conduct of group psychotherapy requires specialized education and training.
Group psychology and group psychotherapy has been recognized as a specialty by the American Psychological Association, which has thus established standards for education and training.
Expansion of standardized education and training is needed to realize the benefits of group psychotherapy.
Editor’s Note: This article is part of a special issue on group psychotherapy with Guest Editor Fran Weiss, L.C.S.W.-R., B.C.D. Although authors were invited to submit manuscripts for the themed issue, all articles underwent peer review as per journal policies.
In 2018, the American Psychological Association’s Commission for the Recognition of Specialties and Subspecialties in Professional Psychology (CRSSPP) recognized group psychology and group psychotherapy (GPGP) as a specialty. (Formal recognition of group psychotherapy as a specialty occurred within the discipline of psychology, but group psychotherapy is practiced by psychiatrists and other mental health professionals. In this article, the terms “group psychotherapy” or “group therapy” are intended to be inclusive of groups led by all of these professionals.) Although group psychotherapy is widely practiced, enhances access to needed treatment, and is a proven treatment modality, some practice and training sites erroneously believe that it does not require specialized training, knowledge, skills, or practices. The recognition of group psychotherapy as a specialty has therefore become an inconvenient truth for those wishing to ignore these training needs. This article outlines what a specialty is, how group psychotherapy qualified for specialty status, and the basics of how educational programs can align with specialty training standards.
The Public Need for Group Psychotherapy
U.S. mental health needs have never been greater. Even prior to the COVID-19 pandemic, during which the prevalence of mental health conditions has increased from 15% to more than 40% (1), mental health problems were worsening across a wide range of populations and settings (2). The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) 2019 National Survey on Drug Use and Health (3) has shown steady increases in mental disorders, with increases in major depression, severe mental illness, and any mental illness shown for every age range. Concomitantly, opioid addiction is a national epidemic, causing the loss of 128 people per day. Mental health diagnoses have been rising alarmingly among some age groups, with young adults showing increases of more than 10% for any mental illness and of more than 4% for severe mental illness over a 10-year period. The second leading cause of death for individuals ages 15–34 years is suicide, with one person dying by suicide every 11 minutes in the United States (4).
The desire to seek services for mental health problems has also increased. A recent national study (5) showed that 141 million adults in the United States (56%) have actively sought or wanted to seek treatment for themselves or others they know. Mental health services, however, are both underfunded and understaffed (6), and there are not enough clinicians to serve the nation’s needs. This deficit has created an access problem, with one survey finding that, nationally, only one in four individuals are able to access needed mental health services (5). Access problems have particularly affected underserved populations, with rural and low-income areas experiencing lower access to services.
The solutions to these problems are manifold, but provision of mental health treatment that is efficacious and accessible is an important part of any national strategy. Group therapy offers many solutions to this problem of access to effective treatment by providing the opportunity to improve population health by lowering rates of the most prevalent mental health conditions (6). As a treatment modality, group therapy offers evidence-based models of practice and has been validated for a wide variety of conditions, including many of the most prevalent and severe conditions (7), and it is cost-effective (8, 9). Group psychotherapy also provides benefits to culturally diverse populations (10). Specifically, group psychotherapy’s effectiveness has been demonstrated across the lifespan (see GPGP Specialty Council Petition [11] for relevant citations), among ethnically diverse populations (12), among those with diverse gender and sexual orientations (13, 14), and among special populations, including patients with HIV/AIDS (15), veterans (11), and incarcerated persons (9, 16).
Utilization of Group Therapy
Group therapy utilization is difficult to determine at the national level because data sets are dispersed across multiple payment sources and agency providers and are not always available to the public. However, the data available suggest widespread usage of group therapy as a primary or adjunctive treatment across a wide range of settings. Medicare data indicate that group therapy is the second most utilized psychotherapy nationally (17). Moreover, group therapy is the dominant treatment modality within the Veterans Health Administration (18). Surveys of utilization in prisons, which house the nation’s largest number of mental health patients, have shown (19) that group therapy is used for at least 20% of their services. Group psychotherapy is also recommended by SAMHSA (3) for addictions treatment, and groups are the mainstay of many such treatment programs throughout the country. Add in the prevalence of therapy groups in skilled nursing facilities, community mental health centers, primary care offices offering integrated care, and school settings, and a picture of widespread utilization emerges. Despite these data, some clinician training programs consider group therapy a niche treatment and offer little to no training. The utilization data suggest this reasoning is flawed. Group psychotherapy and group psychology are fields with rich histories and a deep base of literature and research, as seen in this special issue.
Variability in Training
Despite group therapy’s potential to improve access to mental health treatment, training standards remain varied. (Because the organizations involved in making group psychotherapy a specialty were psychology organizations, the standards have applicability only to psychology training programs and the practice of psychologists, though they likely offer value to other disciplines.) A recent survey of agencies revealed little attention to group attendance, insufficient measurement of process and outcomes, and generic supervision typically serving as the only quality control (20). Anecdotal evidence suggests that many providers and mental health agency administrators mistakenly believe that group therapy is a treatment delivery system for other therapies, rather than a treatment modality itself, and therefore does not require specialist training. The refrain, “If you can do individual therapy, then you can do group therapy,” is often heard in training and practice settings. This is a mistaken assumption. Achieving GPGP specialty status required demonstrating that GPGP has unique processes, techniques, and evidence bases. Without this foundation, unqualified and unskilled practitioners are left to lead groups with inadequate preparation, little understanding of group dynamics, lack of knowledge or skills to intervene, and little discernible accountability for outcomes. Without specialized expertise, group psychotherapists can both contribute to and fail to mitigate adverse outcomes (21).
What Is a Specialty and Who Qualifies as a Specialist?
The CRSSPP was established within the American Psychological Association to “identify, codify by recognition, and clarify for the public distinctive patterns of education, training, and practice that exist among professional psychologists” (22). The CRSSPP states that, “A specialty is a defined area of professional psychology practice characterized by a distinctive configuration of competent services for specified problems and populations. Practice in a specialty requires advanced knowledge and skills acquired through an organized sequence of formal education, training, and experience in addition to the broad and general education and core scientific and professional foundations” (23). Thus, specialty recognition applies to training, which is acquired during psychology doctoral programs, internships, postdoctoral fellowships, and/or at the postlicensure level and which must go beyond the generalist training expected at each level. Training programs are therefore the focus of this article. The CRSSPP recognizes specialties related to the direct provision of health services and those related to the provision of applied professional services.
Although the CRSSPP recognizes specialties at the training program level, it does not credential individual psychologists nor limit their practice. Instead, licensing boards, legislation and other regulations, and ethical principles and codes of conduct regulate the practice of individual psychologists in the same way they regulate the practice of psychiatrists and other mental health practitioners. In addition to CRSSPP’s ability to recognize specialties, it also recognizes organizations that certify individuals in recognized specialties, such as the American Board of Professional Psychology (ABPP).
Although the focus of this article is not on specialty credentialing at the individual level, individuals interested in receiving recognition for competence or mastery can learn more about the two existing credentials. These credentials are conferred by the ABPP, which offers board certification for psychologists in GPGP that is recognized by the CRSSPP (https://www.abpp.org/Applicant-Information/Specialty-Boards/Group-Psychology.aspx) and by the International Board for Certification of Group Psychotherapists (https://www.agpa.org/cgp-certification/), an entity of the American Group Psychotherapy Association (AGPA), which certifies candidates from almost all mental health disciplines and offers the Certified Group Psychotherapist credential.
Establishment of the GPGP Specialty
GPGP is unique in that it combines two areas that differ in their type of service provision. Group psychologists typically provide applied professional services, whereas group psychotherapists typically provide health services. Because the American Psychological Association recognizes specialties in either type of service, training programs in group psychology, group psychotherapy, or both are eligible for recognition. However, because the American Psychological Association only accredits programs in health service psychology, the standards for education and training are more clearly established for programs in this area (4). Although the GPGP-approved specialty petition places greater emphasis on group psychotherapy than on group psychology, work is increasing to better integrate these areas (24).
The CRSSPP established 12 criteria (25) needed to achieve specialty status as well as an application and renewal process by which a field can establish that it meets these criteria, which GPGP was required to meet (11). Many of these criteria are beyond the scope of this article or have been discussed above. However, the criteria that explain issues such as diversity (criterion III), the distinctiveness of group therapy (criterion IV) and training standards at each level of training (criteria V, VI, and VII) are germane to this article’s purpose—to describe the rationale for the specialty designation and to indicate training standards that programs should consider—and are discussed below.
Diversity (Criterion III)
Training and practice issues in diversity have become ever more important to the mental health field, and group therapy can uniquely contribute to this area. Although general training is expected to prepare group psychotherapists to practice in accordance with the American Psychological Association’s multicultural guidelines (26) and professional practice guidelines applicable to practice with particular populations (see https://www.apa.org/practice/guidelines), multicultural training and competence specific to GPGP go beyond this routine training.
An example of GPGP-specific diversity training is the identified need to train group psychotherapists to be able to respond to microaggressions in groups. Microaggressions have been studied in other modalities of psychotherapy (27), and their harmfulness has been clearly established. Microaggressions in group psychotherapy are complex and pose increased risk of harm, because often there can be multiple perpetrators, targets, and/or bystanders present and exponentially more factors influencing the group psychotherapist’s response (28). Accordingly, a growing body of literature has addressed microaggressions in group psychotherapy (29), continuing education has offered increased opportunities to train group psychotherapists to respond to microaggressions in group psychotherapy (30), and relevant GPGP competencies have been developed, including demonstration of the ability to effectively intervene when microaggressions occur in a group (31). The nuances of leader-member, member-member, and member-group interactions add complexity to interventions, thus requiring skills from the group leader beyond those provided in individual psychotherapy training.
Distinctiveness (Criterion IV)
The CRSSPP also requires specialties to demonstrate how they are distinct from one another. GPGP has distinctive theoretical underpinnings (32). Although there is overlap with other mental health specialties (e.g., clinical, counseling) in the populations treated, GPGP uses distinct techniques and procedures. The group-specific therapeutic factors (33) and mechanisms of change (34) of group psychotherapy are examples of the depth and breadth of constructs operating within any group. Therapeutic factors in group therapy, such as group cohesion and interpersonal skills, interact in complex ways with group dynamics, leadership skills, setting, and treatment type. Group psychotherapists must have intervention skills that are able to address those complexities (33, 35). As Yalom and Leszcz (33) have suggested, premature dropout, which can result from failure to manage these complexities, can result in double demoralization, because already demoralized patients often experienced worsened symptoms after feeling they have failed at the treatment meant to help them. Put simply, group therapy, like other therapies, can be iatrogenic when led poorly.
A growing body of evidence has shown the benefits of the use of specialized assessment in group therapy (36, 37) to augment clinical judgment. Group therapy–specific assessment tools enhance the group leader’s ability to assess group readiness (e.g., Group Readiness Questionnaire [38]), monitor group process (e.g., Group Questionnaire [39]), and assess factors affecting screening, process, and outcomes, such as interpersonal distress (e.g., Inventory of Interpersonal Problems [40]). These tools, which can be used as part of an evidence-based practice approach to enhance therapy in real time, formed part of the case for achieving specialty status (11).
Effectiveness and Quality Improvement (Criteria IX and X)
The CRSSPP also requires specialties to support the effectiveness of their practice and to demonstrate that such investigation is ongoing. Rosendahl et al.’s review of research in this special issue (41) sheds light on the empirical inquiry taking place nationally and internationally. Group psychotherapy has been shown to be as effective as individual therapy for most patients and disorders (42, 43). Moreover, an increasing body of meta-analyses have supported the efficacy of group psychotherapy for particular disorders, such as anxiety (44) and depression (45), and research on therapeutic factors, such as the impact of group cohesion on outcome (46), is ongoing. Systematic reviews (47) also provide helpful overviews of group efficacy research and illustrate the breadth and depth of the literature related to this specialty.
Specialty Accreditation and Alignment of Training Programs
As previously mentioned, group leader training is ripe for improvement, with sites and institutions varying widely in the quality and quantity of their offerings (48). Although there are excellent programs for group therapy (e.g., Brigham Young University’s Counseling Center and Harvard University–affiliated McLean Hospital), there is wide variation in the quality of practice across settings and populations. Few programs have clear standards for staff in terms of training and preparation in group psychotherapy, other than reliance on licensure. Approval of GPGP as a specialty set the standards for remedying this situation. The following guidelines and standards are germane to the process of offering specialty training.
Practice Guidelines (Criterion XI)
GPGP practice guidelines exist under several organizations. Most salient to the American Psychological Association’s recognition of GPGP as a specialty are the Association’s Division 49 Clinical Practice Guidelines (49), which are currently in draft form and can be found online. Division 49’s GPGP Specialty Council’s strategic objectives include finalization of these practice guidelines. Previously, AGPA’s Science to Service Task Force had published practice guidelines for group psychotherapy (50); efforts to update these guidelines are also underway. Finally, the Association for Specialists in Group Work has also released practice guidelines (51). There is extensive alignment among all these guidelines. The guidelines have been designed to inform training programs about material that would be suitable for training clinicians and can therefore serve as a guide for those wishing to offer specialty training.
Training Guidelines
Training programs at each training level (i.e., doctoral, internship, postdoctoral, and postlicensure) of psychology training are able to promote their GPGP specialty training if they can demonstrate their alignment with the standards laid out in criteria V, VI, and VII and in the GPGP Education and Training Guidelines. (The current GPGP guidelines can be found at https://www.apadivisions.org/division-49/leadership/committees/group-specialty; the guidelines will be reformulated in a pending manuscript that is being developed under the auspices of the GPGP Specialty Council.)
Taxonomy
The American Psychological Association has developed a taxonomy (25) to provide an organizing framework and consistent terminology for education and training in psychology health services specialties. In particular, these guidelines encourage education and training programs to use the following terminology when referring to their specialty training: major area of study, emphasis, experience, and exposure. Programs that offer GPGP must comply with the taxonomy (Table 1). Additionally, specialty accreditation (52) for postdoctoral residency programs is defined by the American Psychological Association through their Council on Accreditation, which is currently awaiting recognition.
| Stages of education and training | ||||
|---|---|---|---|---|
| Level of training | Doctoral | Internship | Postdoctoral | Postlicensure |
| Major area of study | 96 hours didactics, between doctorate and internship to include practicum | Didactics (see doctoral); 50 hours as facilitator or cofacilitator and 30 hours supervision | 80%–100% of residency to include didactics, clinical practice, supervision, and presentations | 50 hours organized CE, 50 direct hours with supervision in specialty |
| Emphasis | 48 hours coursework and supervised practicum as group leader or group coleader | N/A | 30%–50% didactics on advanced group leadership, clinical issues, supervised experiences | 25 hours organized CE, direct clinical contact with supervision in specialty |
| Experience | 20 hours didactics and 10 hours as a training group member | N/A | 20%–29% didactics on advanced group leadership, clinical issues, supervised experiences | Some CE at conference with part-time (supervised) practice in specialty |
| Exposure | 1 entry-level group course | N/A | <20% didactics on advanced group leadership, clinical issues, supervised experiences | Some CE on clinical aspects of practice or university course in specialty |
TABLE 1. Stages of group psychology and group psychotherapy traininga
Standards
Standards differ by level of training and intensity (11). Programs have to intentionally train in GPGP (rather than incidentally), provide didactics in GPGP through coursework or other modalities, and provide clinical experience in GPGP supervised by specialized supervisors. Overall, programs must provide training that will enable trainees to meet postdoctoral residency competencies before independently practicing (https://www.apadivisions.org/division-49/leadership/committees/postdoctoral-residency-group.pdf). Not all trainees within a program must obtain specialty training, but the program must offer all components of the GPGP specialty in a manner that would allow a trainee to complete the training.
Aligning Training Sites to Standards
Offering training that is in alignment with standards is within reach for most strong group therapy programs and creates an opportunity for these programs to stand out. All that is required is that the programs make the case for their quality on the basis of standards laid out in this article. In many cases, these standards have already been met; strong group programs should contact the Group Specialty Council for guidance. Tools, resources, and further organizational structures are in development to assist training programs to meet these standards, advertise their services appropriately, and be recognized for providing specialty training to potential trainees and the group psychology and psychotherapy community.
Conclusions
The future of quality improvement in the field requires training and practice settings to embrace the need for specialized training in group therapy. With more sites adopting training standards, specialty status provides the opportunity to improve patient access and outcomes through the provision of enhanced leadership skills among practitioners. Training programs aligning with standards for education and training in GPGP have an opportunity to join the efforts to promote high-quality outcomes in group therapy by showcasing their commitment to evidence-based work. Programs that provide comprehensive group specialty training are vindicated in that choice and present an inconvenient truth to those seeking to relegate group practice to the untrained.
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