Group Effectiveness
Group therapists are often left wondering why some therapy groups, or even individual group sessions, are more or less effective. The two recent process research studies highlighted here provide some conceptual tools to help therapists explore this question.
Li, X., Kivlighan, Jr D. M., Paquin, J. D., & Gold, P. B. (2021). What was that session like? An empirically-derived typology of group therapy sessions. Group Dynamics: Theory, Research, and Practice, 25(2), 107-121. http://dx.doi.org/10.1037/gdn0000139
In the present study, Li and colleagues set their goals on developing a parsimonious and clinically meaningful typology that captures and organizes what happens in group therapy sessions, in terms of unique configurations of work, emotional and defensive processes. The authors used archival data from two groups to conduct a cluster analysis of clients’ aggregated scores on the Group Climate Questionnaire-short form (GCQ-S; MacKenzie, 1983). The GCQ identifies three dimensions of group climate: engaged (e.g., “The members liked and cared about each other.”), avoiding (e.g., “The members appeared to do things the way they thought would be acceptable to the group.”), and conflict (e.g., “The members were distant and withdrawn from each other.”). The GCQ is the most commonly used measure of group process (Orfanos et al., 2020) and research has shown it to be a strong predictor of psychotherapy outcome. The authors used two very different types of groups to develop a typology that may be applicable to a wide range of groups and assess potential differences between groups. One of the groups was a manualized trauma-focused treatment provided to 73 incarcerated women divided into six groups that met twice a week for 11 weeks. The other group was an unstructured interpersonal group for university students enrolled in a group counseling course. Thirty-six students were divided into four groups that met twice a week for 14 weeks.. Group members in each group completed the GCQ-S after each session. A total of 230 sessions were used for this study.
Results of the cluster analysis yielded five distinct patterns which were labeled as: prickly standoffish (Type 1), polite working (Type 2), heavy going (Type 3), harmoniously involved (Type 4), and negatively distancing (Type 5). Thus the signficiant findings offered support for the authors’ proposition that different types of sessions can be identified. With regard to the two groups studied, the majority of sessions (75.7%) were classified as prickly standoffish (characterized by slightly below the mean engagement and slightly elevated avoiding and conflict on the GCQ dimensions) and polite working (characterized by slightly elevated engagement and slightly below average avoiding and conflict). These two types are seen as representing less intense or deep group work, consistent with the idea that group members often feel more comfortable remaining at a more superficial level to avoid emotionally engaging in the here-and-now process (Yalom & Leszcz, 2020), whether by avoiding unspoken conflicts or by relating in overly cautious ways (Type 2)
Findings further showed that the structured trauma groups of incarcerated women were more likely to engage in the more “surface-level” type of sessions whereas the unstructured interpersonal process groups were more likely to experience the heavy going, harmoniously involved, and negatively distancing types which represent more intense forms of therapeutic work. The authors note that these results are consistent with what group psychotherapy theorists have conceptualized in the past, namely that a structured approach where roles and rules are tightly scripted can protect group members from the free flow and riskiness of more intense emotional work (Corey, 2011; Yalom & Leszcz, 2005). However, other factors such as differences in group composition or treatment length could have impacted the outcomes of the study.
Finally, the current study’s results showed that the session types were likely to be similar from one session to the next, supporting the authors’ hypothesis of the existence of a “perseveration effect.” Li and colleagues base this concept on existing models of group development, such as Tuckman and Jensen’s five-stage model (1977) and MacKenzie and Livesley’s four-stage model (1983; 1997). These models suggest that group progress is not random but follows a series of distinct stages. In the present study, Li and colleagues posit that group climate is likely to follow a similar pattern of continuity across sessions as session types are likely to persevere from one session to the next. This means that clinicians can evaluate the stage of group development their group is in by referring to the previous sessions’ type. Understanding of this effect can also help clinicians to prepare for future sessions. In addition, the results of the study revealed that similar session types were likely to follow each other. Specifically, a more positive session type is more likely to be followed by another positive one than by a more negative session type. Li and colleagues expand on this idea by explaining that each group’s uniqueness can be described as a “group personality” that remains stable over the course of treatment and manifests in the climate of the group.
In sum, the results of this study provide important and novel information regarding group typology that group practitioners can use to gain insight into their group process. Although the authors highlight some limitations that could be addressed in future research, the classification system that emerged from the study provides helpful information to assist in group conceptualization by providing a more nuanced framework to think about what happens in group and how the the specific configuration of work, emotion and defensive processes that characterize one session is likely to impact future sessions. The promising findings from this study should assess the applicability of this model with other types of groups.
References:
Corey, G. (2011). Theory and practice of group counseling (8th ed.). Belmont, CA: Thomson Brooks/Cole.
MacKenzie, K. R. (1983). The clinical application of a group climate measure. In R. R. Dies & K. R. MacKenzie (Eds.), Advances in group psychotherapy: Integrating research and practice (pp. 159-170). Madison, CT: International Universities Press.
MacKenzie, K. R. (1997). Clinical application of group development ideas. Group Dynamics: Theory, Research, and Practice, 1, 275-287. http://dx.doi.org/10.1037/1089-2699.1.4.275
MacKenzie, K. R., & Livesley, W. J. (1983). A developmental model for brief group therapy. In R. R. Dies & K. R. MacKenzie (Eds.), Advances in group psychotherapy: Integrating research and practice, (pp. 101-135). Madison, CT: International Universities Press.
McClendon, D. T., & Burlingame, G. M. (2010). Group climate: Construct in search of clarity. In R. K. Conyne (Ed.), The Oxford handbook of group counseling (pp. 164-181). New York, NY: Oxford University Press.
Orfanos, S., Burn, E., Priebe, S., & Spector, A. (2020). A Systematic review and quality assessment of therapeutic group process questionnaires. International Journal of Group Psychotherapy, 00, 1-30. http://dx.doi.org/10.1080/00207284.2020.1755292
Tuckman, B.W., & Jensen, M. A. C. (1977). Stages of small-group development revisited. Group & Organization Studies, 2, 419-427. http://dx.doi.org/10.1177/105960117700200404
Yalom, I. D., & Leszcz, M. (2020). The theory and practice of group psychotherapy (5th ed.). New York: NY: Basic Books.
Wei, M., Wang, L. F., & Kivlighan Jr, D. M. (2021). Group counseling change process: An adaptive spiral among positive emotions, positive relations, and emotional cultivation/regulation. Journal of Counseling Psychology.
For too long group therapists for children and adolescents have had little literature to draw from to inform their understanding of what makes group therapy effective for children. Recognizing this gap in the literature, Wei and colleagues (2021) sought to provide some insights for this critical area of practice. Specifically, they applied Yalom and Leszcz’s (2005) theory of adaptive spirals to test posited reciprocal relationships between students’ positive emotions, their perceived social support, and emotional cultivation/regulation (i.e., their awareness of emotion consequences, action control, and capacity for regulating emotions) in emotional counseling groups for adolescents.
In an adaptive spiral, a group member’s “interpersonal distortions diminish and her or his ability to form rewarding relationships is enhanced. Social anxiety decreases; self-esteem rises; the need for self-concealment decreases” (Yalom & Leszcz, 2005, p. 49). Furthermore, it is posited that, “Others respond positively to this behavior and show more approval and acceptance of the patient, which further increases self-esteem and encourages further change” (Yalom & Leszcz, 2005, p. 49). Therefore, the therapeutic progress of the other members of a group influences an individual group member’s own progress and vice versa. As Wei and colleagues state, this process is much “like when flowers open up and see that the world is larger, and they can catch more of the light to flourish their growth.” (p. 2).
Using advanced statistical methods, Wei and colleagues modeled longitudinal self-report ratings of positive emotions, positive relationships, and emotional cultivation to test the idea of whether adaptive spirals of these constructs can be discerned over the course of a therapy group. Results indicated a reciprocal model with positive emotions and relationships being associated with greater future emotional cultivation and subsequently emotional cultivation being associated with greater future positive emotions and relationships (i.e., the upward spiral or adaptive spiral effects). Simply stated, this study found that positive emotions, positive relations, and emotional cultivation reciprocally influence each other to create optimal growth.
Group process research on child/adolescent group therapy is limited, and as such the findings are meaningful for the practice of adolescent/child group therapy in several ways. First, this study provides further support for the importance of common factors in group therapy, namely positive emotions and positive relationships. Group therapists can enhance the outcomes of emotional therapy group for adolescents through promoting positive emotions, such as gratitude and focusing on positive relationships between peers and students and teachers. Conversely, cultivating emotional strategies (see Wei et al., 2021) similarly can enhance students’ positive relations and positive emotions.
Although this study is informative, one lingering question in research utilizing longitudinal data is how many data points are sufficient to test adaptive spirals or reciprocal relationships over time. Although Wei and colleagues (2021) utilized more repeated assessments than previous research on adaptive spirals in group therapy (e.g., Kivlighan et al., 2016; Paquin et al., 2013), their analyses were limited to four data points. Future research should seek to provide more guidance on how many data points of time are useful to provide a clinically meaningful and valid test of this undoubtedly complex relationship over time. Related, it would be helpful to understand if providing group leaders with feedback on the presence of adaptive or maladaptive spirals during the course of therapy can facilitate the development of effective interventions to promote adaptive spirals or intervene when maladaptive spirals are occurring. Given the lack of process research in the adolescent/child group therapy literature, the findings from this study will hopefully inform the practice of emotional therapy groups for children by, at the least, giving therapists some useful conceptual guideposts.
References:
Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56, 218–226. https://doi.org/10.1037/0003-066X.56 .3.218
Kivlighan, D. M., III, Paquin, J. D., Hsu, Y.-K. K., & Wang, L.-F. (2016). The mutual influence of therapy group members’ hope and depressive symptoms. Small Group Research, 47(1), 58–76. https://doi.org/10.1177/ 1046496415605638
Paquin, J. D., Kivlighan, D. M., III, & Drogosz, L. M. (2013). If you get better, will I? An actor-partner analysis of the mutual influence of group therapy outcomes. Journal of Counseling Psychology, 60, 171–179. https://doi.org/10.1037/a0031904
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: NY: Basic Books.