Running head: CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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Core Principles of Conducting Group Psychotherapy
Michelle P. George
University of Wollongong
Author Note
This paper was submitted to fulfil the requirements for PSYP923 on the 8th April 2020 wc 2059
CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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Core Principles of Conducting Group Psychotherapy
Psychological treatments which are conducted as groups form an integral part of schoolbased mental health programmes. The three-tiered approach cites, group treatment is provided
when identified groups of students require interventions which may be focussed on specific goals
or risk prevention (McKenzie, Vidair, Eacott & Sauro, 2017). This paper aims to provide an
outline of some core principles in conducting group psychotherapy with a focus on school
psychologist practitioners. The following report is organised around principles found in the
American Group Psychotherapy Association (AGPA) Practice Guidelines for Group
Psychotherapy (see Appendix A) which incorporate APS standards of respect, propriety and
integrity. The core principles include: Starting well; understanding therapeutic factors and
therapeutic mechanisms; understanding group development and group processes; reducing
adverse outcomes; and planning for the termination of the group. These principles can apply to
any psychotherapy group, but some issues of concern for school psychologists will also be
considered.
Group therapy is a specialised form of psychotherapy, whereby several clients confront
their personal problems together with the guidance of a therapist or co-therapists. (Barlow,
2008). Groups that have been organised for the purpose of psychological change come in a
variety of theoretical leanings and may be targeted to specific populations. For example,
psychodynamic group therapy for people with personality disorders (Kvarstein et al., 2017) and
group-based cognitive behavioural therapy for anxiety (Espejo et al., 2017). Despite the different
theoretical leanings and goals, many of these groups share the same basic principles. In that, all
psychotherapy groups aim to remedy mental disturbances and interpersonal difficulties in people.
Rather than just interacting one to one with a therapist, groups provide the opportunity to interact
CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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with others, so the group provides an immediate experience of testing their insights and trailing
new skills (Dishion & Stormshak, 2007). Group psychotherapy uses the ‘group entity’ as an
agent for change in-that interactions that take place between group members are an essential
ingredient of the therapeutic process (Barlow & Burlingame, 2006). The assumption is that
individual dynamics, interpersonal dynamics, and ‘group as a whole’ dynamics all work together
to provide a vehicle of change (Bernard et al., 2008). The combination of these dynamics as a
therapeutic mechanism is often referred to as group cohesion (Burlingame et al., 2001; Yalom &
Leszcz, 2005). There is a vast body of research exploring group dynamics and the benefits of
group therapy (Corey & Corey, 2016).
School psychologists may be asked to provide group therapy for a target population
within the school community. As part of the scientist-practitioner model, finding credible
evidence that a group-based intervention is effective or at least not harmful is the first priority.
For example, two Cochran reviews of group-based psychotherapy for adolescences who selfharm found that it was not supported or the evidence was of low quality (Hawton et al., 2015;
Vincent, 2016). However, for people with autism spectrum disorder, social skills groups are
recommended. The results of a Cochran meta-analysis found that participants in social skills
groups made clinically significant gains in social competence and experienced better friendships
(Reichow et al., 2012). Finally, one more Cochran review cites evidence that group‐based
parenting programmes improved behaviour in children along with reducing anxiety, stress and
depression in parents (Furlong et al., 2012). Peer reviewed literature will assist in deciding
whether a group-based program is appropriate. Once a decision has been made to run a group for
a targeted population to achieve the desired goal, the AGPA guidelines provide direction so that
the intervention can be implemented efficiently and ethically.
CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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School psychologists will need to navigate the ethical complexity of multiple clients
(group members, teachers and the school as a whole) and proactively address issues before they
arise. For example, a psychologist may be asked to provide group therapy for students at their
school; in doing so, they find that teachers are not supportive of the intervention. The AGPA
guidelines provide support in the first section, Starting Well: Administrative Collaboration. It
suggests that psychologists gather evidence from the literature and stakeholders to provide a
credible program which will be appreciated and embedded into the school context. Arranging
meetings and providing information about the practicalities such as timeframe and specific goals
of the intervention will help to gain support for it (Bernard et al., 2008).
Before a group-based program can commence, all students will require parent or guardian
consent to participate (Australian Psychological Society, 2018). Under the APS Code of Ethics,
groups of people are clients (APS p. 8) and as such, are treated with respect regarding informed
consent and confidentiality. However, the issue of how a practitioner will manage an individual’s
privacy with the other group members is a problem encountered with group work. The AGPA
recommends that group leaders pay special attention to establishing group norms around
disclosure of information and confidentiality that respect the rights of everyone in the group. An
agreement can take the form of a group contract or expectations which explicitly state group
member rights and responsibilities (Bernard et al., 2008). Once norms have been agreed upon,
the therapist needs to maintain and manage the agreement as part of setting up a therapeutic
alliance at each meeting. The psychologist should be particularly mindful that the group
members will have existing relationships with each other outside the group, such as classmates
or friends. This adds more complexity to issues surrounding confidentiality. Goffman (1961)
explored a process called ‘looping’, where inpatients had confidential information that they
CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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disclosed in the therapy group fed back to them (via group members and staff) in other social
contexts. Uncertainty around privacy undermines the safety of the group as a therapeutic
environment and may impede participants from sharing personal information (Pepper, 2004).
Special consideration around respect needs to be reinforced by the therapist and privacy is
dependent on the actions of the group members.
Providing group-based psychotherapy is complex and requires specific skills in group
dynamics (Yalom & Leszcz, 2005). AGPA guidelines provide a framework for understanding
these dynamics in the Group Development and Group Process sections. Group development
theory helps the therapist plan the intervention with time limitations and provides a model for
testing hypotheses around particular group behaviour (Corey & Corey, 2016). Development
models also provide a predictable sequence of events that a likely to occur in all groups such as
Tuckman’s (1965) Five-Stage model of forming, storming, norming, performing and adjourning
(Tuckman, 1965). MacKenzie (2004), describes group developmental classification in four
stages: Engagement, differentiation, interpersonal work, and termination. During engagement,
participants find similarities and get to know the boundaries of the group as a place that is
different to the outside world. In the differentiation stage tensions are realised and worked on
before moving into the more personal issues during the interpersonal work phase. The
termination phase is important for consolidation of changes made during the group. Group
development stages are useful for predicting and understanding the group member’s behaviour.
Knowledge of group process will assist the therapist in harnessing the therapeutic factors
which belong to the group and are outside of the therapist or a particular method. For example
group cohesion is assumed to be a psychological construct belonging to the group as a whole; it
is considered a therapeutic mechanism akin to the therapeutic relationship (Johnson et al., 2005).
CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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Cohesion is construed as something positive in the mind of the participant, it contains factors of
relationship bonds and agreement on tasks and goals (Schnur & Montgomery, 2010). Fostering a
cohesive environment is essential to change in group psychotherapy in the same way that
therapeutic relationship is essential to individual therapy (Yalom & Leszcz, 2005). This is often
seen early in the development of the group, in the “engagement” stage when everyone is cordial
and working towards the same goal (MacKenzie, 2004). Group cohesion is also used as a gauge
of progress that can be monitored by the therapist. Several cohesion questionnaires have been
developed to be used as outcome measures for therapy, making it easier for psychologists to
monitor change in the group and individuals (Gleave et al., 2017). Cohesion measures can
provide valuable feedback to the program’s participants and stakeholders, they also contribute to
data collection as part of the scientist-practitioner model.
While conducting the group, instances will arise that seem less cohesive and more
confrontational. Therapists are subjected to multiple transferences from individual group
members or subgroups within the group. Personal and professional boundaries become more
complicated because of the multiple relationships that exist in the group Self-refection and
identifying countertransference are ways of avoiding reactions which may reflect poorly on the
therapist’s conduct (Tasca et al., 2016). For example, group leaders may consciously or
unconsciously collude with the group members in scapegoating (MacKenzie, 2004).
Scapegoating refers to projecting unwanted self-aspects onto another person who is labelled as
deviant (Moreno, 2007). A scapegoat can protect the group leader, instead of confronting the
therapist directly with their frustration, the group members attack the scapegoat. The group
leader needs to be aware of this and not join the group's efforts to confront or correct the person
being used as a scapegoat (Moreno, 2007).
CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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The AGPA’s guidelines state how the management of countertransference is more
difficult in groups compared to individual therapy in the Individual Member and Leader Roles,
section. It is essential to recognise if reactions emerge from the therapist's unresolved issues or if
they are induced by interaction with the group. Understanding and working through scapegoating
as a group phenomenon can be underpinned by a variety of theories (Finlay et al., 2016). In the
context of school psychology, drawing attention to what has taken place in the group regarding
scapegoating could be useful and often reflects issues such as bullying (Dixon, 2007). It is the
psychologist’s responsibility to intervene so that no group member is harmed by hurtful or
stigmatising exchanges (MacKenzie, 2004). For example, the therapist can keep the behaviour
in-check by asking what other members think about the exchange. The therapist can then guide
the discussion into a more in-depth exploration of the issues and possibly serve as a model for
the group. Reducing adverse outcomes from scapegoating is yet another challenge that is unique
to group work.
As in individual psychotherapy, termination of the therapy sessions should be planned for
in group psychotherapy. Planning for termination is essential for helping members who have had
difficult or traumatic departures in the past. Group members will display various reactions to the
dissolution of the group such as sadness, anxiety or abandonment. The therapist is responsible
for reviewing and reinforcing the gains made during the sessions and provide a space that helps
members process feelings of ambivalence during termination (Bernard et al., 2008). As the
AGPA guidelines recommend, this can be done via a celebration or a ritual. Group members may
say something positive about the group or another group member. Positive statements or
observations can be written down for each person, anonymously, and handed out for participants
to keep. By doing this, the psychologist normalises the combination of positive feelings and
CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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feelings of sadness associated with ending. They will also reinforce the interpersonal gains made
and provide a role model for future goodbyes (Bernard et al., 2008).
This paper provides a summary of some core principles of conducting group
psychotherapy and highlights a few of the issues which could be faced when providing group
therapy in schools. The AGPA’s Clinical Practice Guidelines for Group Psychotherapy (2008)
were designed to provide to “support for practitioners of group psychotherapy to meet the
appropriate demands for evidence-based practice and provide greater accountability in the
practice of contemporary psychotherapy” (Bernard et al., 2008, p 456). The core principles
include making thorough preparation before the group commences with consideration to
evidence-based practice, obtaining consent from multiple clients. Establishing group norms are
core to managing confidentiality and establishing a group climate of safety. The core principle of
cohesion is vital as a therapeutic mechanism of change; it is also a means to measure progress
which informs the scientist-practitioner. Reducing adverse events and facilitating a supportive
ending to the sessions are crucial to conducting group psychotherapy. Although the task of
conducting group psychotherapy is complex and fraught with challenges, there is a high demand
for group-based services as they are an effective form of therapy for a variety of conditions
(Blackmore et al., 2012; Burlingame, 2018; Reavley, Bassilios, Ryan, Schlichthorst, Nicholas,
2015).
CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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Important References
*** Yalom, I. D., & Leszcz, M. C. (2005). The theory and practice of group
psychotherapy (5th edition). This book is like the bible of group-therapy. The original work was
published in 1967 and the most recent edition 2005, it is amazing that it contains the same core
concepts and is still relevant for student’s learning group psychotherapy today. Almost every
article on group Psychotherapy cites the work of Yalom. This work is elegantly written and easy
to follow with footnotes, including additional clarification and supporting research.
**Bernard, H., Burlingame, G., Flores, P., Greene, L., Joyce, A., Kobos, J. C., Leszcz,
M., Semands, R., Piper, W., Mceneaney, A., & Feirman, D. (2008). Clinical practice guidelines
for group psychotherapy. International Journal of Group Psychotherapy, 58(4), 455–542. This
paper was authored by the Science to Service Task Force of the American Group Psychotherapy
Association, chaired by Drs. Kobos and Leszcz. It provides practitioners with clear and concise
information regarding the core principles of group psychotherapy as well as guidelines for
handling issues that arise in group settings regardless of the theoretical orientation of the
intervention. The principles are relevant to diverse client populations in a variety of treatment
settings, including schools. These guidelines were due to be reviewed in 2015; however, a more
recent edition could not be found.
* MacKenzie, K. R. (2004). The alliance in time-limited group psychotherapy. This
chapter in The Therapeutic Alliance in brief Psychotherapy provides some valuable insights for
therapists from MacKenzie who has contributed a vast amount of research in the field of group
psychology. Again, the literature seems old; however, no recent contributions provide a clearer or
more concise explanation of the concepts in group psychotherapy. This chapter gives the
CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
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practitioner a guide to the basic principles of group therapy and includes a copy of the Group
Climate Questionnaire for therapists to use.
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Barlow, S. H. (2008). Group psychotherapy specialty practice. Professional Psychology:
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Barlow, S. H., & Burlingame, G. M. (2006). Essential theory, processes, and procedures for
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Semands, R. R. M., Piper, W. E., Mceneaney, A. M. S., & Feirman, D. (2008). Clinical
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experiential avoidance in group-based transdiagnostic CBT for anxiety disorders. Journal of
Anxiety Disorders, 46, 65–71. https://doi.org/https://doi.org/10.1016/j.janxdis.2016.06.006
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CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
Apendix A
The AGPA Practice Guidelines for Group Psychotherapy
1. Creating successful therapy groups
i.
Starting well—Client referrals
ii.
Starting well—Administrative collaboration
2. Therapeutic factors and therapeutic mechanisms
i.
Mechanisms of change in group psychotherapy
ii.
The therapeutic factors
iii.
Cohesion—A core mechanism of change
iv.
Relationship of cohesion to other therapeutic factors
v.
Evidence-based principles related to group cohesion: Group structure, verbal
interaction, emotional climate
vi.
Assessment of therapeutic mechanisms in clinical practice
3. Selection of clients
i.
Inclusion criteria
ii.
Exclusion criteria
iii.
Premature termination
iv.
Patient Selection Instruments
v.
Composition of therapy groups
4. Preparation and pre-group training
i.
Objectives of preparation: Establish the therapeutic alliance, reduce patient
anxiety, provide information, consensus on treatment goals
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CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
ii.
Methods and procedures
iii.
Impact and benefits
5. Group development
i.
Models of group development and assumptions
ii.
Developmental stages
6. Group process
i.
The group as a social system
ii.
Work, therapeutic and anti-therapeutic processes
iii.
The group as a whole
iv.
Splits and subgroups
v.
The pair or couple
vi.
The individual member and leader roles
7. Therapist interventions
i.
Executive function
ii.
Caring
iii.
Emotional stimulation
iv.
Meaning attribution
v.
Fostering client self-awareness
vi.
Establishing group norms
vii.
Therapist transparency and use of self
8. Reducing adverse outcomes and the ethical practice of group psychotherapy
i.
Professional ethics
ii.
Group pressures
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CORE PRINCIPLES OF CONDUCTING GROUP PSYCHOTHERAPY
iii.
Record keeping
iv.
Confidentiality, boundaries and informed consent
v.
Dual relationships
vi.
Preventing adverse outcomes by monitoring treatment progress
9. Concurrent therapies
i.
Concurrent group and individual therapy
ii.
Combining group therapy and pharmacotherapy
iii.
Twelve step groups
10. Termination of group psychotherapy
i.
Unique aspects of termination in group therapy
ii.
Time-limited groups
iii.
Open-ended groups
iv.
Premature termination
v.
Ending therapy with personal satisfaction
vi.
A dilemma of the open-ended group
vii.
Ending rituals
viii.
Therapist departures
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