Research roundup: How to build a more effective therapy group

New studies on group psychotherapy point to ways clinicians can reduce patient attrition and improve patient outcomes.

In this installment of Research Roundup, we look at three of these studies: One that explores the balance of positive and negative feedback in group therapy, one that looks at how individuals’ stages of change are influenced by general change mechanisms, and a third that investigates the role of patient fit within the therapy group.

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.

Kivlighan, D.M., III, Ali, R.W., & Garrison, Y.L. (2019). Is there an optimal level of positive and negative feedback in group therapy? A response surface analysis. Psychotherapy. Advance online publication. http://dx.doi.org/10.1037/pst0000244

Previous research has demonstrated that feedback is an important therapeutic factor in group therapy and that both negative and positive feedback are necessary to foster group cohesion and promote behavioral change (Lieberman, Yalom and Miles, 1973; Yalom and Leszcz, 2005). But how much feedback of each type is necessary to improve patient outcomes?

In this study, the authors hypothesized that high levels of both positive and negative feedback would be optimal for member’s perceptions of cohesion and improvement.

Study participants were 168 graduate and undergraduate college students partaking in 43 interpersonal process therapy groups across 10 university counseling centers. Individual diagnosis information was not provided, but patients at the participating counseling centers were often referred to interpersonal process groups for depression, anxiety, adjustment disorder, and interpersonal difficulties.

During the second to last session of each group, members were asked to complete questionnaires, rating the degree to which each member of their group gave them positive feedback and negative feedback. Participants were also asked to indicate their perceived level of cohesion in the group using the Group Entitativity Measure (GEM; Gaertner and Schopler, 1998) and to complete the Patient’s Estimate of Improvement scale (PEI; Hatcher and Barends, 1996).

Analyses found that members who reported receiving high levels of positive feedback and low levels of negative feedback had the highest perceptions of group cohesion. However, members who reported high levels of both positive and negative feedback also experienced significantly positive perceptions of group cohesion.

The reverse was true for perceptions of improvement such that members reporting high levels of both positive and negative feedback perceived the highest levels of improvement while those reporting high levels of positive feedback and low levels of negative feedback also experienced significant positive perceptions of improvement.

Members’ perceptions of improvement were the lowest when perceptions of positive and negative feedback were both low or if they perceived low positive feedback and high negative feedback.

The findings suggest that group leaders may want to attend to the amount and balance of positive and negative member-member feedback to enhance the clinical benefit of group therapy services.

Specifically, group leaders may want to:

• Take the time to discuss the role and benefit of both positive and negative feedback as well as explore members’ reactions to giving and receiving feedback
• Model giving both positive and negative feedback
• Explore barriers that might be preventing the exchange of positive and negative feedback
• Explore individuals’ perceptions of member-member feedback to ascertain whether their perceptions of the amounts of positive and negative feedback are accurate

Schaller, G., Blanck, P., Vogel, E., Vonderlin, E., Bents, H. and Mander, J. (2018). Therapeutic processes in group therapy: Intersections between general change mechanisms and motivational stages of change from patient perspective. European Journal of Psychotherapy & Counselling, 20(3), 312–336. http://dx.doi.org/10.1080/13642537.2018.1495247

In this study, the authors sought to determine how individuals in group therapy change through the lens of two models of the therapeutic process in individual therapy: Grawe’s psychological therapy model and Prochaska’s transtheoretical model. By applying both models, the authors could explore patients’ individual motivational stage and general change mechanisms.

These change mechanisms are broken down into two categories: experiential change mechanisms (ECMs) and behavioral change mechanisms (BCMs). ECMs heighten the awareness of a problem and include problem actuation (being in touch with the emotions of the problem), clarification of meaning, and emotional bond. BCMs, in contrast, focus on behavioral processes that lay the ground for and enhance the patient’s active work on an issue and include mastery/coping, resource activation, and task and goals.

The authors hypothesized that ECMs are important for cultivating early stages of change precontemplation and contemplation and that BCMs are key to encouraging later stages of change action and maintenance.

Participants were 140 adult outpatients attending a variety of group therapies, averaging eight sessions, in conjunction with individual therapy in Germany. Patients completed measures looking at demographics, symptomatology, motivational stages of change, mechanisms of change, and group cohesion at the beginning of group therapy and then again at the end.

The study results support the hypothesis, specifically finding that patients who experienced higher levels of ECMs at the start of group therapy reported higher levels of contemplation at the end of therapy. In addition, patients reporting higher levels of BCMs at the start reported higher levels of action at the end.

These results highlight the importance of using specific change mechanisms (experiential versus behavioral) that best match the patient’s motivational stage of change (precontemplation and contemplation to action and maintenance).

With this finding in mind, psychologists may wish to determine patients’ motivational stages of change before beginning group psychotherapy. Forming therapy groups made up of patients in similar stages of change may be preferable since it allows the clinician to focus on either experiential or behavioral processes. Individual stage of change can be assessed using motivational interviews or with self-report measures such as the URICA-S.

Cruwys, T., Steffens, N.K., Haslam, S.A., Haslam, C., Hornsey, M.J., McGarty, C., & Skorich, D.P. (2019). Predictors of social identification in group therapy. Psychotherapy Research. Advance online publication. http://dx.doi.org/10.1080/10503307.2019.1587193

Previous research has found that group leaders and members overwhelmingly rate group dynamics as a key driver of positive change in group psychotherapy (Burlingame, McClendon and Alonso, 2011). One way to look at group dynamics is through the construct of social identification, or the degree to which a person subjectively feels that a group positively informs their self-definition (Postmes, Haslam and Jans, 2013).

For this research, the authors looked at contextual factors of social identification, specifically how and when people choose to categorize themselves and others in terms of a specific group membership. The authors focused on this degree of fit in two separate studies.

In the first study, the authors used a measure of perceived similarity, the degree to which patients perceived members of their treatment group to be relatively homogeneous at the start of therapy, to predict social identification at the end of therapy. Participants were 103 psychiatric outpatients who completed group cognitive behavior therapy (CBT) for depression or anxiety based on their primary diagnosis. Because most patients were experiencing comorbid symptoms of several mental illnesses, participants varied in their “match” between the patients’ symptom profiles and their assigned therapy group.

Patients completed questionnaires with items measuring social identification, perceived similarity, and depression symptoms on the first day of therapy after group introductions and at the end of the CBT program. Results indicated that participants who felt that members of the group were similar to one another at the beginning of therapy were more likely to identify strongly with the group at the end of therapy. Additionally, participants were more likely to identify with their CBT group to the extent that they perceived the group to be a good fit with the personal circumstances (i.e., level of symptom severity and assignment to a depression focused versus anxiety focused group).

The authors sought to replicate these findings in the second study, using an objective measure of similarity instead of a perceived measure. Participants were 112 young women with body shape or weight concerns who participated in an eating disorder prevention program. Before the first session and after the final session, group members completed outcome measure questionnaires asking about demographics, height and weight, eating disorder symptoms, and thin ideal internalization. Shorter questionnaires were completed after each session that measured social identification.

The results conceptually replicated the findings of the first study. Participants experienced a larger increase in their social identification with the therapy group based on placement in groups with members who were more similar on a salient dimension, such as their body mass index. Additionally, participants identified more strongly with the therapy group when their symptom profiles were closer to the group treatment focus—in this case, having high thin ideal internalization or low eating disorder symptoms.

These findings suggest that practitioners may want to consider patient fit with a therapy group before recruitment starts. For example, deciding what to call the group, how it will be advertised, and how patients will be screened may affect a patient’s perception of whether they will fit within a specific group.

Another factor for psychologists to consider is how similarly patients will believe they are to other group members with respect to symptom-specific features related to the purpose of the group (i.e., weight in an eating disorder prevention group). Shared experiences and goals, rather than demographic characteristics, may make it more likely for patients to identify with other group members.