George Washington University
Department of Professional Psychology
The Group Psychologist Winter/Spring Issue 2024 Pre-Doc Forum
Social Identity in the Group: An Asian American Reflection
Jung In Park, M. Psy
Social Identity in the Group: An Asian American Reflection
Social Identity has been defined by Ribeiro (2020)as an understanding and sense of the self based on the members of their group and as an entity that remains fluid in nature depending on the developmental and environment changes that inevitably occur around us. In individual therapy, holding space for a person’s social identities may make room for the exploration of identity development, family and trauma history, and a deeper understanding and ecological perspective on one’s presenting concerns. Social identity also provides opportunities for the understanding and use of the transference and countertransference reactions in the context of similar and/or different identities of the therapist and patient that interact and how this may be affecting or aiding the treatment process. Group work provides a canvas for viewing the individual patient and their social identities within a relational space, where each individual’s identities that are brought to the space can impact other group members in ways that are different, unconscious and/or reminiscent of familiar dynamics, struggles or conflicts within and outside of the group (Ribeiro, 2020). As do my other colleagues in my doctoral clinical psychology program, I find myself approaching clinical work with a desire to better understand our patients and their lived experiences and to find connection with them through the shared space as they find healing. Oftentimes, this involves discussions around my patient’s social identities, how they locate themselves, how they view their own identities and what aspects of their identities have been historically and systemically disavowed or oppressed. From this process I have found it imperative to pursue an examination of my own social identities, and how this contributes to who I am as a person and as a burgeoning clinician. Without examining my own identities, how may I continue to grow deeper insight about myself and therefore the collaborative, therapeutic process? As a second generation, Korean American, third-culture kid (TCK), I have experienced multiple anxiety-provoking situations of entering or joining spaces where there is no other person who looks like me, shares my identities, cultures, or languages. Beginning my clinical training and exploring my identity as a clinician interested in gaining group psychotherapy experience has allowed me the space and opportunity to contend with and consolidate many of my experiences, and to be curious about my own presence and anxieties as a participant and member in group processing spaces during my training.
While reflecting on my anxieties that emerged in group processing spaces, one prominent feeling that I had recurrently felt was the self-doubt regarding the value and validity of my own experiences in America as an Asian American female. I can recall frequently debating with myself whether my encounters with microaggressions, racism, and feeling “othered” paled in comparison to the oppression and violence that other communities of color in the United States experienced. Looking back, my personal experiences with assimilation and acculturation as a TCK along with my internalized ideas regarding the “model minority myth” had resulted in my presence in group processing spaces to be filled with silence as a way to deal with this internal debate. The silence I experienced within myself and demonstrated outwardly quickly ballooned into an intense anxiety, resulting from both the internalized habit of questioning my experiences in a White supremacist society as well as the destabilizing feelings of guilt and shame that I was potentially aligning with the “oriental”, “perpetual foreigner,” “model minority” and meek stereotype of the Asian person that exists in the West. This brings me to the question I have begun to ask myself: Where do my fears of speaking and resulting silence emerge from, and what history does it represent? How does it affect others around me? This was a difficult internal experience for me to make sense of, especially given the relative lack of discourse and literature regarding the Asian American experience in my educational setting and the larger field of Psychology.
From my perspective, Yoo, Gabriel and Okazaki’s (2022) research and expansion on Asian American Psychology provided me with a meaningful framework to better understand my internal experiences and difficulties viewing myself as a member in group spaces. Their work aims to advance research within Asian American Psychology by incorporating an Asian Critical Race Theory and from an Asian Americanist Perspective. Asian Critical Race Theory (AsianCrit), building on the tenets of Critical Race Theory, offers the conceptual groundwork for understanding the structural, institutional, and cultural aspects of a society that champions Whiteness and how Asian Americans in the United States are “racially stratified and uniquely positioned between… White supremacy and anti-Blackness” as a way to justify unique forms of White supremacy against Asian Americans (e.g: exclusionary laws) (p. 568). An Asian Americanist perspective recognizes and encourages the heterogeneity, hybridity, and multiplicity in experiences of Asians in America by focusing on community strengths and structural change, as well as calling attention to how Asians in the United States currently and historically have challenged and been complicit in anti-Blackness (R. M. Lee & Tseng, 2021; N. Tran et al., 2018). Psychological literature on the Asian American experience is often narrow and “overrepresent[s] the role of traditions, values and customs of Asian ethnic groups” while “underrepresent[ing]… the roles of racial formation and stratification of Asians in the United States and their unique racialized history of struggle, resilience, and protest” (Yoo et al., 2022, p. 565). Furthermore, there is limited recognition of intersectional identities which often results in the erasure of the experiences of brown Asian Americans, low-income Asian Americans, multiethnic and multiracial Asian Americans, LGBTQ+ Asian Americans, disabled Asian Americans and religious minority Asian Americans (Yoo et al., 2022).
As I reflect on my own fearful withdrawal into silence and what this brings into a group space, it became clearer to me that I had internalized an Asian American identity that had been constructed as a means to uphold White supremacy by pitting Asian Americans against other racial minority groups (Azhar et al., 2021). The introduction of the “model minority” in 1960s America served to “rationalize that systematic racism is not real” and to devalue and locate the economic struggles of other racial minorities within the individual rather than the system while making a mythical, “nonpolitical” and “exemplar case of ethnic assimilation” of new Asian immigrants (pg. 571). Furthermore, stereotypes and portrayals of Asian women as being demure, submissive, and quiet, generated feelings of guilt around my anxiety-stricken silence while simultaneously having to contend with an internalized “model minority myth” that forbade me from speaking my own truth. From a relational-cultural perspective, neglecting to view the sociocultural or relational context can lead to individually located shame but understanding one’s relational self and capacities within the sociocultural context allows one to move away from a place of shame and instead lead with an authentic and empathic connection to others (Hartling et al., 2000; Walker, 2001). Intersectional social identities may complicate people’s experiences with bias and discrimination, and thus taking on a critical perspective on one’s internal experiences would be essential in dismantling internalized stereotypes and allowing a more authentic presence within a group space (Azhar et al., 2021).
With the COVID-19 pandemic came the significant spike in anti-Asian hate, discrimination, and violence which I experienced first-hand, and have continued to hear stories from my community members about ongoing fears and encounters. I found myself feeling disconnected from my own experiences and my desire to find support with others. By dismantling the harmful stereotypes and addressing internalized perceptions that Asian Americans may have of themselves through the use of critical theory, it may help to expand our curiosity and understanding of how our experiences and social identities emerge within the group processing space. While this reflection barely scratches the surface of the structural, institutional, and cultural forces that have shaped and structured the erasure of Asian American voices, there is clarity on the need for greater discussions regarding the experience of the Asian American person in the United States within the field of Psychology and group psychotherapy. This is especially needed, given the significant rise of anti-Asian rhetoric, discrimination and violence following the COVID-19 pandemic. Further discussions may address intersectionality to shine light on how an ableist, cis and heteronormative society has erased the voices of those who land at various points of intersectionality. It is an important consideration on the part of group leaders and in the clinical training of group psychotherapy to hold in mind the intersecting and interacting dynamics that may occur within the group setting, which can then create space for deeper understanding and healing.
References
Azhar, Alvarez, A. R. G., Farina, A. S. J., & Klumpner, S. (2021). “You’re So Exotic Looking”: An Intersectional Analysis of Asian American and Pacific Islander Stereotypes. Affilia, 36(3), 282–301. https://doi.org/10.1177/08861099211001460
Hartling, L. M., Rosen, W., Walker, M., & Jordan, J. V. (2000). Shame and humiliation: From isolation to relational transformation (Work in Progress No. 88). Wellesley, MA: Stone Center Working Paper Series.
Ribeiro, M. D. (2020). Examining social identities and diversity issues in group therapy: Knocking at the boundaries. Routledge/Taylor & Francis Group. https://doi.org/10.4324/9780429022364
Tran, N., Nakamura, N., Kim, G. S., Khera, G. S., & Ahn Allen, J. M. (2018). #APIsforBlackLives: Unpacking the interracial discourse on the Asian American Pacific Islander and Black communities. Community Psychology in Global Perspective, 4(2), 73–84. https://doi.org/10.1285/i24212113v4i2p73
Tseng, & Lee, R. M. (2021). From margin to center: An Asian Americanist psychology. The American Psychologist, 76(4), 693–700. https://doi.org/10.1037/amp0000866
Walker, M. (2001). When racism gets personal: Toward relational healing (Work in Prog- ress No. 93). Wellesley, MA: Stone Center Working Paper Series.
Yoo, Gabriel, A. K., & Okazaki, S. (2022). Advancing Research Within Asian American Psychology Using Asian Critical Race Theory and an Asian Americanist Perspective. The Journal of Humanistic Psychology, 62(4), 563–590. https://doi.org/10.1177/00221678211062721
Attachment Style and Group Psychotherapy in Prison Settings
Melanie Helvick, M.A.
Professional Psychology Program, George Washington University
Group treatment is a frequently utilized form of psychological service in prison settings. Groups in prisons are economical, allowing practitioners to work with more people in a limited time span (Lester, 2000). In a population that is so desperate for services, continuing to use group treatment as a way to reach more patients is essential. With the reliance on group treatment in prisons, there is also need for continuing research on the unique characteristics of the offender population and how to best approach intervention. Attachment theory is an important lens through which to view all modalities of group therapy. In an offender population, the complexity of attachment styles potentially present in a prison treatment group calls for an evaluation of how attachment theory may be used to inform practice. Current research on group therapy in prison settings has largely focused on the use of structured treatment modalities, particularly cognitive-behavioral therapies. Expanding this research to see how we may incorporate attachment theory in any group, regardless of orientation, is vital. Such knowledge has the potential to significantly help leaders facilitate change with offenders and allow for greater relational growth in these prison settings.
Cognitive-behavioral and other structured groups such as psychoeducational or skill development groups are a necessary feature of treatment within prison populations. Much of the current literature on group therapy in prisons has focused on the effectiveness and positive outcomes of these groups. Most generally, Andrews et al., (1990) posits that directive, cognitive-behavioral approaches are recommended over non-directive groups, particularly with offenders experiencing more disturbance. A review of group psychotherapy approaches by Morgan and Flora (2002) puts forward data suggesting that cognitive behavioral approaches in treatment programs with offenders produce the most beneficial results. It has also been suggested that the inclusion of homework exercises alongside cognitive-behavioral strategies and general structure has led to better outcomes with offenders (Morgan, Kroner, & Mills, 2006). Though these approaches to group have undoubtedly led to improvements in prison settings, it is suggested that a missing component of this work is an examination of more deeply rooted experiences in their early relationships and an incorporation of how explorations of these factors can have profound impacts on offenders (Ansbro, 2008).
Without discounting the importance of cognitive-behavioral and structured modalities of group therapy in prison settings, some researchers have inquired about the importance and effectiveness of more relational, non-directive aspects of treatment as well. Morgan and Winterowd (2002) explored the use of interpersonal process-oriented group psychotherapy (Yalom, 1995), defined in this setting as “exploration of inmates’ interpersonal relationships with each other as well as their relationship with group facilitators” (p. 466). Morgan and Winterowd (2002) suggest that for a range of incarcerated offenders, this approach may have potential advantages that other approaches to group therapy cannot offer, mainly regarding how members learn to relate to one another. Potential benefits of this treatment approach may include helping inmates gain insight into themselves and how they interact with others and helping them learn to become responsible for their interpersonal behavior as they grow and develop (2002). Thinking about relational factors in groups more broadly, researchers have also suggested that while structure and cognitive-behavioral strategies are essential for inmate change, group processes can and should be incorporated into more structured group treatment, in order to reap the benefits of such approaches. It is proposed by Morgan, Kroner, and Mills (2006) that centering of interpersonal dynamics at various times during a variety of group treatment modalities, to help the inmates understand their behaviors, their impact, and how others respond to them.
This growing acknowledgment of the importance for offenders to interact with interpersonal dynamics and engage with process-oriented approaches to treatment brings up important questions for researchers on relational factors between group members and leaders, particularly in how individual attachment styles may be showing up in interpersonal interactions. The available literature on group therapy has not widely looked at groups through an attachment theory lens, one that has great potential to inform how relational aspects could be incorporated into more structured groups. Researchers have investigated a variety of approaches to group psychotherapy that are based on attachment theory (Marmarosh et al., 2013). Even beyond these approaches specifically developed to include attachment considerations in their model, Marmarosh and colleagues (2013) also argue that attachment theory can, and should, be applied to all approaches to group therapy. They state that, regardless of the orientation of the group leader, attachment theory supports the idea that change is facilitated between members of the group (Marmarosh et al., 2013). As such, current group therapies in prison settings, regardless of modality, may give thought to how attachments play out with their group members and how attachment theory can be integrated into practice.
When considering the potential impact of attachment dynamics on the function and effectiveness of any modality of group therapy, it is important to evaluate the present research on attachment styles and offending behaviors. While not specifically focused on group therapy, some researchers have studied how attachment theory can be applied to offenders more broadly. Looking at general trends in attachment styles of offenders, research has suggested that insecure attachment, rather than secure attachment is strongly associated with all types of criminal behavior, both violent and non-violent offending (Ogilvie et al., 2014). When investigating, more specifically, convictions for violence and interpersonal difficulties in a group of inmates, Hansen and colleagues (2011) found the presence of an anxious attachment style explained most of the variances in aggression in intimate relationships. Ogilvie and colleagues (2014) desired to look more closely at some differences amongst subgroups of offense type and found “some suggestion that violent offenders and rapists are more dismissive in their attachment style, whereas child sexual offenders tend to be more anxious” (p. 337). Attachment theory has also been applied to the broader category of sexual offenders (Goldenson et al., 2007; Grady et al., 2016; Rich et al., 2005) and also to substance use/dependence (Flores, 2001). While these offender groups are not monoliths and understanding most common attachment styles does not replace evaluating unique styles of group members. According to Goldenson and colleagues (2007), this research can serve a better understanding of how, and in what cases, attachment styles might be related to criminal behavior and therefore, treatment focus.
There have been some group programs with offenders which have begun to consider attachment styles. Adshead (2011) reported on her narrative approach to psychodynamic work with offenders in a secure hospital setting. She identified her approach as an acknowledgement of the relevance of past attachment experiences and their influence on linguistic variabilities in how offenders communicate about their past and current attachment experiences. According to Adshead (2011) positions these dynamics and their role in identity creation through narratives and describes the power of her narrative approach to allow people to self-reflect and change their narratives, particularly surrounding their offenses. Some Therapeutic Communities in prison settings have also incorporated attachment perspectives into their models of treatment. Interpersonal connections according to Miller and Klockner (2019) investigated the application of attachment theory in Australian Therapeutic Communities where therapeutic work is conducted in groups of varying sizes with a goal to facilitate growth through interpersonal relationships. According to Miller and Klockner (2019), there were shifts in attachment styles over time through these treatments, with “some positive attachment-based change across all groups” and an overall decrease in insecure attachment and increase in secure attachment. They reported support for the idea that relationships in therapeutic groups are a strong mechanism of change and suggested further research for attachment-based change with larger samples (Miller & Klockner, 2019).
Understanding the attachment styles of group members can provide a wealth of information in selection of groups and navigating interpersonal dynamics in the group room. When group therapists are aware of the likely insecure attachment styles that may show up in a group session composed of offenders, facilitators may do well to make adjustments to some of their practices. Group leaders may consider screening for attachment styles with potential members of the group with the aims of creating a group composed of similar or intentionally different styles. If multiple group types are available, this screening may inform who is more suited to a more structured cognitive-behavioral group that might incorporate relational and mindfulness practice, and who might be prepared to enter into a more process oriented, less-directive group. When beginning therapy, group leaders may consider how they present the therapeutic frame to members and emphasize efforts to prepare each person for being in a group treatment setting. It is also important to consider the self-reflective functioning of each member and their ability to regulate emotion (Ansbro, 2008). An emphasis on openness and tolerance as a prerequisite to engaging is important in all modalities of treatment, but especially in groups.
Attachment theory brings to group psychotherapy great insight into how people interact with one another and in navigating relationships. When it comes to those who have engaged in offending behavior, understanding the potential insecurity of early attachments and how this may affect current functioning within groups is vital for group treatment. Without discounting the importance of structured, cognitive-behavioral group approaches with this population, group leaders may consider how they can incorporate attachment theory into practice, perhaps in exploring interpersonal phenomena, in screening and preparing potential members, or in simply facilitating a group in which attachments can be explored. Due to the widespread use of groups in prison settings, a better understanding of how attachment styles function in groups of offenders is a vital piece in helping group leaders navigate this specialized type of treatment.
References
Adshead, G. (2011). The life sentence: Using a narrative approach in group psychotherapy with offenders. Group Analysis, 44(2), 175-195.
Andrews, D. A., Bonta, J., & Hoge, R. D. (1990). Classification for effective rehabilitation: Rediscovering psychology. Criminal justice and Behavior, 17(1), 19-52.
Ansbro, M. (2008). Using attachment theory with offenders. Probation Journal, 55(3), 231-244.
Flores, P. J. (2001). Addiction as an attachment disorder: Implications for group therapy. International journal of group psychotherapy, 51(1: Special issue), 63-81.
Goldenson, J., Geffner, R., Foster, S. L., & Clipson, C. R. (2007). Female domestic violence offenders: Their attachment security, trauma symptoms, and personality organization. Violence and victims, 22(5), 532-545.
Grady, M. D., Swett, L., & Shields, J. J. (2016). The impact of a sex offender treatment programme on the attachment styles of incarcerated male sexual offenders. Journal of Sexual Aggression, 22(1), 123-136.
Hansen, A. L., Waage, L., Eid, J., Johnsen, B. H., & Hart, S. (2011). The relationship between attachment, personality and antisocial tendencies in a prison sample: A pilot study. Scandinavian journal of psychology, 52(3), 268-276.
Lester, D. (2000). Group and Milieu Therapy. In P. Van Voorhis et al. (Eds.), Correctional Counseling and Rehabilitation (3rd ed., pp. 189-217). Routledge.
Marmarosh, C. L., Markin, R. D., & Spiegel, E. B. (2013). Attachment in group psychotherapy. American Psychological Association.
Miller, S., & Klockner, K. (2019). Attachment styles and attachment based change in offenders in a prison Therapeutic Community. Journal of Forensic Psychology Research and Practice, 19(3), 260-277.
Morgan, R. D., & Flora, D. B. (2002). Group psychotherapy with incarcerated offenders: A research synthesis. Group Dynamics: Theory, Research, and Practice, 6(3), 203.
Morgan, R. D., & Winterowd, C. L. (2002). Interpersonal process-oriented group psychotherapy with offender populations. International Journal of Offender Therapy and Comparative Criminology, 46(4), 466-482.
Morgan, R. D., Kroner, D. G., & Mills, J. F. (2006). Group psychotherapy in prison: Facilitating change inside the walls. Journal of Contemporary Psychotherapy, 36, 137-144.
Ogilvie, C. A., Newman, E., Todd, L., & Peck, D. (2014). Attachment & violent offending: A meta-analysis. Aggression and violent behavior, 19(4), 322-339.
Rich, P. (2005). Attachment and sexual offending: Understanding and applying attachment theory to the treatment of juvenile sexual offenders. John Wiley & Sons.
Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). Basic Books.
The Group Psychologist Fall Issue 2023 Pre-Doc Forum
Transforming a Flawed System: Reevaluating the Training and Practice of Group Therapy
Zach Goldman LCSW
Doctoral Student – Clinical Psychology
The George Washington University
Prior to enrolling in a psychology doctoral program, I worked as an independently licensed clinical social worker. As a social worker, I provided therapeutic interventions across a wide variety of settings, including a medication assisted treatment facility for patients with substance use disorders, a residential facility for patients with eating disorders, a college counseling center, a group private practice, and, finally, in my own private practice. While on my trajectory through each of these clinical placements, I began to notice a few trends. First, I noticed that there seemed to be a negative correlation between my level of experience and the severity of my patients’ mental illnesses. The less experienced I was as a therapist, the more severe the mental health issues of my patients. Second, I noticed that there also seemed to be a similar, negative, correlation between my level of experience and the pressure that I felt to lead group therapy sessions as a new professional. Both of these trends seem problematic.
While I was in each of these different clinical settings, these correlations seemed like strange coincidences. However, after thinking about each of these phenomena more critically, I began to wonder if they were actually coincidences at all. Is it common for less experienced clinicians to work with patients who have severe mental health concerns? Do newer clinicians frequently provide group therapy rather than individual? When I looked at the literature, both appeared to be true. Whittingham et al. (2023) describes how patients with serious mental health issues, who are therefore in settings such as hospitals or intensive outpatient treatment centers, are often treated via group therapy. They also explain that this treatment is frequently led by clinicians who have little experience, and who do not receive adequate training in group therapy. These phenomena are problematic for both the patients and the therapists, and we must make changes to our mental health system in order to prevent this from happening in the future.
The phenomena in question can have a significant negative effect on patients with serious mental health concerns in both the short and long terms, as when clinicians lack expertise in group therapy techniques it is reasonable to posit that the treatment that they provide would be less effective. Group therapy that is less effective is problematic in the short term because it causes patients to continue to suffer. Additionally, when utilizedinappropriately and when ruptures in groups are not adequately addressed, it is even possible that group therapy could increase group members’ suffering. Ineffective group therapy can also be problematic in the long term by either deterring group members from seeking out therapy again, or by causing them to accrue greater healthcare costs via additional treatments.
Not only do the aforementioned phenomena negatively impact group therapy patients, but they also have a similar effect on inexperienced therapists who lead groups, since patients with more severe mental illness can be more emotionally taxing to treat. This emotional tax can be due to a variety of factors, including, but not limited to, different responsibilities for clinicians. For example, when I was a social work student leading groups with patients struggling with significant issues surrounding food and substances, I found the bulk of my time being spent assessing for safety, crisis planning, and re-orienting my patients to the settings we were in.
People with more severe forms of mental illness not only have lower recovery rates than those with less severe forms, but also a life expectancy that is 10-25 years shorter (Fiorillo, 2021). Therefore, it also be said that there is less external reinforcement for clinicians who work with this population when compared to those who work with patients who have less severe forms of mental illness. This decreased external reinforcement, combined with the previously mentioned increased emotional tax that comes from working with people with more severe mental illnesses, can act as a “perfect storm” that leads newly trained clinicians to burn out early on in their careers. I can relate to this firsthand. Early on in my clinical training, when I was working in residential and intensive outpatient treatment centers, I often didn’t feel as if I was helping my patients, I frequently didn’t enjoy the work, and I constantly questioned my future as a therapist. Fortunately, I decided to stick with clinical work despite these feelings, as it was only after I left these settings that I realized how much I actually love clinical work.
I do not think that my experience was unique. I believe that, eventually,many experienced clinicians learn that patients with more severe mental illnesses can be more emotionally taxing for them to treat, yet they are (usually) compensated less for treating them. I also believe that this leads a large number of these clinicians to develop a greater desire to treat people with more mild or moderate mental illness, which motivates them to eventually leave for settings in which they can do so. This being said, it is important to note that, in my experience, more seasoned clinicians have far more career options (and far less desperation for jobs) than do newer clinicians. This is especially true for clinicians who are only provisionally licensed, as positions for them are especially limited. Therefore, it would make sense that after experienced clinicians leave, and their agencies become understaffed as a result, the clinicians who take their places in working in “less desirable settings”, or inpatient settings for people with severe mental illnesses, are primarily newly licensed or still in training.
Again, my experiences support this explanation. When I was gaining clinical experience early on in my career I was specifically interested in individual therapy, and I had little interest in group therapy. Therefore, I looked for clinical settings in which I could either practice or observe individual therapy, however my search was fruitless. I eventually landed in the settings where I did because they offered me the opportunity to practice a limited amount of individual therapy in addition to my primary responsibility, group therapy. While I was in these settings, my coworkers and co-group leaders were usually newer clinicians as well. This being said, I know of very few clinicians who stayed as group therapists after gaining more experience, and most of them, as was similar to myself, eventually became solely individual therapists in private practice. This migration towards private practice can be understood by the significantly higher degree of autonomy that comes with private practice, as it allows therapists to set their own schedules, fees, and treatment approaches. The financial benefits can also be compelling, as therapists can establish their rates and retain the full fees from clients. Furthermore, private practice is logistically simpler and less emotionally draining compared to managing the complex dynamics that are inherent in group therapy.
Since group therapy is often the default treatment modality for people with severe mental illness, and since clinicians who lead these groups are often not very experienced, I therefore believe that the way in which we commonly use group therapy is problematic. For example, even though I have led numerous therapy groups, prior to beginning my doctoral program, I had never been enrolled in a course that was focused specifically on group therapy. I have had courses where group therapy was addressed, but the amount and depth of training that I received for group therapy was nowhere near that for individual therapy. I have led group treatments for patients with serious needs, yet I can confidently say that I was not trained in group treatment. Needless to say, these treatments were doomed to have problems.
To make our use of group therapy more beneficial for patients and newer clinicians, clinical programs must provide students with more comprehensive training in group therapy. Since my master’s program did not offer any course that was specific to group therapy, this “more comprehensive training” could even be a single “Intro to Group Therapy” course. The need for more comprehensive training in group therapy throughout clinical programs is especially the case since, as previously mentioned, young clinicians often begin their clinical training in group therapy settings. When I led groups in the settings previously mentioned, there was a common understanding that new clinicians were not adequately trained to lead groups; however, the sentiment towards these clinicians seemed to be one of “sink-or-swim” or “learn by doing.” These places justified this sentiment by partnering new therapists with co-leaders, as these co-leaders could both help “train” the new therapists and also “clean up the mess” that they oftentimes made in their groups. This is problematic for multiple reasons. For example, not only do patients in these groups have to endure this “mess” before it is “cleaned up,” but they also often become apprehensive of group therapy as a modality.
I saw this dynamic playout firsthand when I observed one of my first groups while in training at a residential eating disorder facility. In this group a less experienced therapist (who for this purpose we will call Sarah), was leading a session with the support of an experienced co-leader (who we will call Mark). During the group in question, a discussion about body image and self-esteem emerged. Sarah attempted to facilitate the discussion, but she unintentionally singled out a few of the group members. It quickly became apparent that many of the patients in the group became visibly uncomfortable. At this point Mark, the experienced co-leader, recognized the escalating tension and tried to intervene by redirecting the conversation and offering a more empathetic perspective. However, the damage had been done, and the patients’ trust in the therapy group had been shaken. Sarah’s inexperience had created an environment where some patients felt judged and misunderstood. Following this incident, several patients expressed their apprehension about the group and Sarah’s competence as a therapist, and it took lots of time and effort to rebuild their trust in the therapeutic process. This scenario could have been largely avoided had Sarah been better trained in group dynamics.
In addition to requiring that group therapy be more comprehensively addressed in clinical programs, we must also address the fact that group is the primary intervention utilized in inpatient settings, and that it is under-utilized in outpatient treatments. One way to address this imbalance is to better compensate clinicians who are working in inpatient settings, where patients suffer from severe mental illness. If we were to better compensate these clinicians their jobs would become more desirable, which could help inpatient settings retain more of experienced clinicians, which could lead to an increased ability to provide both group and individual therapy. Additionally, the group therapy that could be provided would be led by more experienced clinicians, which could lead to more improved outcomes for patients, which could lead to a bolstered reputation for group therapy as a whole.
Another approach that could help improve our current system is requiring group therapists to possess a unique credential such as Certified Group Psychotherapist (CGP, see the American Group Psychotherapy website for certification requirements). This credential would better ensure that all group leaders are adequately trained to lead group therapy, which could lead to better outcomes for patients in groups. These outcomes could also lead to a decreased stigmatization of group therapy and challenge the sentiment of group therapy as a “second best to individual therapy” (Whittingham, 2021). Additionally, this credential could also be utilized as another tool to help justify a pay raise in clinicians who utilize group therapy. Not only could this pay raise lead to the outcomes previously listed, but it could also lead to an increase in private practitioners utilizing group therapy (a number that currently only hovers around 5%) since there is currently a poor reimbursement rates for group versus individual therapy (Whittingham, 2021).
When it is performed by appropriately trained therapists, group therapy can be a triple-E treatment, effective, equivalent or more effective than individual therapy, and efficient (Whittingham, 2021). These properties make group therapy the perfect solution to the increased desire for mental health services in America. If group therapy were utilized to meet the unmet needs in the United States, Whittingham, et al. 2021 outlines how the country would save more than $5.6 billion and require 34,473 fewer new therapists. In fact, even if just 10% of the need was met by group instead of individual therapy, 3.5 million more people could be seen. Therefore, I hope that more of our field begins to recognize the utility, and necessity, of group therapy, and that we stop abusing it as a “band-aid” for more systemic problems.
References
Sartorius, N. (2021). Mortality gap and physical comorbidity of people with severe mental disorders: the public health scandal. Annals of General Psychiatry. 20 (52) https://doi.org/10.1186/s12991-021-00374-y
Whittingham, M., Lefforge, N.L., Marmarosh, C. (2021). Group Psychotherapy as a Specialty: An Inconvenient Truth. American Journal of Psychotherapy. 74. 60–66; doi: 10.1176/appi.psychotherapy.20200037
Whittingham, M., Marmarosh, C. Mallow, P., Scherer, M. (2023). Mental Health Care Equity and Access: A Group Therapy Solution. American Psychologist. 78(2).
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Group Psychotherapy’s Potential to Meet the Mental Health Needs of LGBTQ+ Communities
Julio J. Fonseca
Doctoral Student – Clinical Psychology
The George Washington University
I am a first-year Psy.D. student who has recently transitioned from an established career working in communities developing HIV leadership, HIV prevention/education, and public health advocacy in marginalized communities with which I share intersectional identities. I continue to volunteer as a mentor in the community for men in their twenties who are newly diagnosed with HIV. Leaving a direct role in LGBTQ+ advocacy in 2023, when over 520 anti-LGBTQ+ pieces of legislation, with over 220 bills specifically targeting transgender and non-binary people, were introduced nationwide, has been a challenge (Peele, 2023). The desire to stay connected to advocacy while learning the value of group psychotherapy offers a new perspective on supporting the mental wellness of LGBTQ+ communities. This paper will examine the LGBTQ+ community’s mental health needs, opportunities for support and mental health access, and considerations for group leaders seeking to create groups that are LGBTQ+ focused.
LGBTQ+ Community Mental Health Needs
As of 2023, 7.2% of the population of the United States identifies as LGBT (Jones, 2023). (Gallup did not poll regarding the identity of Queer.) This number has been steady since increasing in 2020 and 2021, with most of these folks identifying as bisexual. LGB adults are more likely than heterosexual adults to experience a mental health condition, here defined as a serious mental illness or a major depressive episode, substance use disorder, and suicidal thoughts or planning (SAMSHA, 2023). Transgender people are nearly four times as likely as cisgender individuals to experience a mental health condition (Wanta et al,. 2019). Of note, these data are before the onslaught of anti-LGBTQ+ legislation, which will undoubtedly impact community mental health.
Peer Led Support
In my background in working in HIV advocacy, I have seen how peer-led and peer-driven support and interventions have been able to yield positive outcomes. An evaluation of a provider mentorship program I led for HIV clinicians to mentor newer clinicians on how to deliver HIV care found unanticipated outcomes regarding social support. In addition to process, outcome, impact, and economic evaluations, we asked mentors and mentees open-ended questions regarding their experiences. In both in-person and virtual/distance mentoring cases, a recurring theme among participants was the component of social support. Participants benefited from the technical learning and the feeling of having a social connection as they implemented new practices (Fonseca & Hujdich, 2013).
In addition to providers supporting their provider peers in mentoring, I have had the opportunity to see the effects of peer leaders collaborating with clients specifically to evaluate their care during interventions intended to better health navigation, referral activities, and the provision of informal support. The evaluators typically participated in programs at the sites as clients who were subsequently recruited as peer workers and, in this case, evaluators. This shared identity and experiences in common with living with HIV, and the experience was vital in building trust with clients participating in the interventions. One evaluator reported: “They [clients] want some of what we have. They want some of what we were able to acquire. And so, it makes them easier to talk to. They also know that “we’ve been somewhere else” (Hawk et al., 2019; p.183). Peer evaluators also shared how intentional relationship-building with clients created a strong alliance and trust. Developing conviction, according to (Hawk et al.,2019), “[Peers] take the time to build the relationship with their clients. I think that they have a better chance of getting information than social workers . . . we build a trust within them. They talk to us about stuff that they won’t talk to a social worker, or they won’t say to a nurse, or not even a doctor” (p. 188). Having seen how these different angles of peer-led interventions have had a positive impact and coming from the LGBTQ+ community, I feel a natural draw and connection to group psychotherapy. I can see the potential for group therapy to address community needs.
Group Psychotherapy
While the data and trends regarding the mental health needs of LGBTQ+ communities may seem stark, there are solutions routed in evidence that could offer safer support for members of the LGBTQ+ community. A benefit of group therapy is its efficiency in allowing more people to be reached simultaneously, which could address seeing more patients effectively, lessening wait times for individual therapy. Research has demonstrated that group therapy is not only as effective as individual therapy but, in some cases, can be even more effective due to lessening stigma and a sense of camaraderie that group members experience with their peers addressing shared treatment goals (Pappas, 2023; Burlingame et al., 2013). There are considerations for developing groups and emerging research specific to LGBTQ+ group therapy experiences (Ali & Lambie, 2019; Nerses, Kleinplatz, & Moser, 2015; Scheer, Breslow, Esposito, Price, & Katz, 2020) highlight concerns to remember when planning to engage the LGBTQ+ community.
Considerations for LGBTQ+ group planning
I am currently part of a team developing an LGBTQ process group to be co-led and supervised by other self-identified members of the LGBTQ+ community at the George Washington University Clinic. We aim to foster meaningful connections with others sharing a similar lived experience while enacting queer liberatory processes. In developing an LGBTQ+ process group, we will conduct an initial phone intake and a longer group therapy assessment. As we are recruiting broadly, we are keeping in mind that depending on who responds and who is a good fit, their interests will help shape the group and determine if we need more than one group specific to self-identification and varying levels of comfort with heterogeneity represented within the LGBTQ+ community as it may manifest demographically in the group. Much of the research on experiences in treatment and accessing mental health care is focused on LGB members of the community. Reviewing articles and journals to understand some of the challenges faced by the LGBTQ+ community, the lack of research on transgender and non-binary communities’ experiences in therapy and groups is notable and a research area for significant development.
Our recruitment and intake process builds upon Meyer’s Stress Model (Meyer, 2003) and recent research on Multiple Minority stress and proximal and distal stress’s role in mental health outcomes among LGB people of color (Ramirez & Galupo, 2019). Examining distal and proximal factors captured in a group assessment intake interview can provide group co-leaders with information on navigating participant identities, which could require additional group prep for going into multi-cultural LGBTQ+ communities. Research on Queer, Transgender, Black, and Indigenous people of color, some of the most marginalized LGBTQ+ communities, has shown that therapy can be ineffective, even re-traumatizing for these communities (Arora et al., 2022). Factors contributing to these effects include clinicians perpetuating systemic oppression in the therapy experience through microaggressions, explicit aggressions, and lack of intentionality by providers to address and dismantle systemic oppression in the therapeutic process. (Arora, et al., 2022, pp 503-505) During therapy, individuals found it more beneficial to share a common identity, such as the same sexual orientation, gender identity, or race. This commonality helped to develop a better understanding between the participants and the therapist and made the participants feel more acknowledged and respected. (Arora, et al., 2022, p. 504).
These are a few examples of the intentionality that LGBTQ+ peer leaders should consider cultivating a safer space for LGBTQ+ members. As we continue to enhance the group process approach, we seek to include principles of Liberation Psychology to foster a sense of greater autonomy and freedom among LGBTQ+ group members (Singh et al., 2020). The concept of liberating people through counseling and psychotherapy is an exciting way to collectively examine group members’ potential and growth to address resilience and healing in LGBTQ+ communities at a time when hope may feel distant.
Conclusion
I feel an incredible privilege to be an openly queer-identified clinician in training. With the onslaught of anti-LGBTQ+ legislation and anti-queer and anti-trans rhetoric, the need for support of my broader community, in addition to my other intersections as a Latinx person, is not only urgent but vital. I have benefited from working with LGBTQ+ clinicians in my mental wellness journey, and there is a shorthand and shared language of the experience of living in what I think of as “fabulous and fierce” margins. Seeing someone’s journey and experience of what is possible is vital for LGBTQ+ people. There is magic in queer spaces, where people feel comfortable examining aspects of themselves that may not be comfortable or even possible in other settings.
With Group Psychology and Group Psychotherapy receiving APA recognition as a specialty in 2018 and the subsequent practice guidelines and calls to standardize the training of clinicians (Whittingham, et al., 2021), the timing of coming into group psychotherapy is personally exciting and full of possibilities. With the clear need for more affirming LGBTQ+-centered mental health care, group psychotherapy offers an affordable option for LGBTQ+, particularly BIPOC members of the Queer community. Group therapy can help members of the LGBTQ+ community seeking to process aspects of their identity and queer experience with other community members in a safer environment. In the history of queer liberation and advocacy, a key component has been the ability to nurture and support each other in the community. Our willingness as LGBTQ+ clinicians to disclose our location as queer community members when appropriate could provide significant safety and freedom for those seeking safe spaces to process aspects of their LGBTQ-plus identities.
References
Ali, S., & Lambie, G. W. (2019). Examining the Utility of Group Counseling for LGBTQ+ Young Adults in the Coming Out Process. The Journal for Specialists in Group Work, 44(1), 46–61. https://doi.org/10.1080/01933922.2018.1561775
Arora, S., Gonzalez, K. A., Abreu, R. L., & Gloster, C. (2022). “Therapy Can Be Restorative, but
Can Also Be Really Harmful”: Therapy Experiences of QTBIPOC Clients. Psychotherapy, 59(4),
498–510. https://doi.org/10.1037/pst0000443
Burlingame, G., Strauss, B., & Joyce, A. (2013). Change mechanisms and effectiveness of small group treatments. Bergin and Garfield’s handbook of psychotherapy and behavior change. 640-689.
Fonseca, J. J., & Hujdich, B. (2013, March 20-23). Addressing the HIV Workforce Shortage: Insights and Implications for a National Mentoring Initiative. [Poster Presentation] ACTHIV Conference: American Conference for the Treatment of HIV. Denver, CO., United States
Hawk, M., Riordan, M., Fonseca, J. J., & Maulsby, C. (2019). I Don’t Want the Tray to Tip: Experiences of Peer Evaluators in a Multisite HIV Retention in Care Study. AIDS Education and Prevention, 31(2), 179–192. https://doi.org/10.1521/aeap.2019.31.2.179
Jones, J. M. (2023). U.S. LGBT Identification Steady at 7.2%.pdf. Retrieved from https://news.gallup.com/poll/470708/lgbt-identification-steady.aspx
Meyer, I. H. (2003). Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674
Nerses, M., Kleinplatz, P. J., & Moser, C. (2015). Group therapy with international LGBTQ+ clients at the intersection of multiple minority status. Psychology of Sexualities Review, 6(1), 99–109. https://doi.org/10.53841/bpssex.2015.6.1.99
Pappas, S. (2023). Continuing Education Effective Group Therapy. Monitor on Psychology, 54(2), 31–35. Retrieved from https://www.apa.org/monitor/2023/03/continuing-education-group-therapy
Peele, C. (2023). Roundup of Anti-LGBTQ+ Legislation Advancing In States Across the Country – Human Rights Campaign.pdf. Retrieved from https://www.hrc.org/press-releases/roundup-of-anti-lgbtq-legislation-advancing-in-states-across-the-country
Ramirez, J. L., & Galupo, M. P. (2019). Multiple minority stress: The role of proximal and distal stress on mental health outcomes among lesbian, gay, and bisexual people of color. Journal of Gay & Lesbian Mental Health, 23(2), 145–167. https://doi.org/10.1080/19359705.2019.1568946
Scheer, J. R., Breslow, A. S., Esposito, J., Price, M. A., & Katz, J. (2020). Violence Against LGBTQ+ Persons, Research, Practice, and Advocacy. 135–148. https://doi.org/10.1007/978-3-030-52612-2_10
Singh, A. A., Parker, B., Aqil, A. R., & Thacker, F. (2020). Liberation psychology: Theory, method, practice, and social justice. 207–224. https://doi.org/10.1037/0000198-012
Substance Abuse and Mental Health Services Administration (2023). Lesbian, gay, and bisexual behavioral health: Results from the 2021 and 2022 National Surveys on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/report/lgb-behavioral-health-report-2021-2022
Wanta, J. W., Niforatos, J. D., Durbak, E., Viguera, A., & Altinay, M. (2019). Mental Health Diagnoses Among Transgender Patients in the Clinical Setting: An All-Payer Electronic Health Record Study. Transgender Health, 4(1), 313–315. https://doi.org/10.1089/trgh.2019.0029
Whittingham, M., Lefforge, N. L., & Marmarosh, C. (2021). Group Psychotherapy as a Specialty: An Inconvenient Truth. American Journal of Psychotherapy, 74(2), 60–66. https://doi.org/10.1176/appi.psychotherapy.20200037
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The Group Psychologist Summer Issue 2023 Pre-Doc Forum
Building Alliances Through Cultural Competency in Group Therapy
Linda Nisanova
lnisanova@gwmail.gwu.edu
The George Washington University
Abstract
When building alliances in group therapy, it is important to communicate with others through the lens of cultural competency. In the world of group therapy, many different identities come into play mimicking outside oppression and struggle. These come from places that may be unknown to other members of the group and the facilitators themselves. Additionally, there is an obligation of understanding other viewpoints in their journeys through group therapy, as well as possible practices for future group settings. The process will be uncomfortable however, build a foundation for trust and meaningful discussions which will in turn, form stronger alliances.
Upon starting a course on the strategies and inner workings of a group, I had little experience in knowing how a group functioned. My previous experience as a co-therapist group helped me understand that forming alliances can be a bridging factor between specific groups of people and be a core aspect of group therapy. My previous group comprised women who were mostly people of color. Perhaps, there was a sort of bond building beyond just the recognition of a mental disorder. As Yalom and Leszcsz (2020) elaborate, the macrosystem of the world is often played out in a group setting, as it mimics what the client exhibits when they are outside of the group (p. 56). A client brings to the group their own struggle and their own feelings of oppression. In a sense, what they experience outside the doors of that safe space are replicated and shared in a smaller microscopic environment. Thus, this can often create similar levels of oppression and alliance. As we see Yalom exhibit in the mock tapings of his group sessions (PsychotherapyNet, 2009), certain cultures clash while others form bonds in perhaps their own feelings of being a minority in the outside world. For example, if a woman of color speaks up against how she feels discriminated in the job field, while a White cis male states that there is no discrimination. Another person of color might identify with the first woman and form an alliance. On the other hand, there can be another male let’s say, side with the first man about how they do not personally see that struggle. This idea of microaggressions comes from a place of inherent lack of perspective and a place of privilege. A common theme we see is the voice of the majority overshadowing those who are more vulnerable. According to the preface of Examining Social Identities and Diversity Issues in Group Therapy, Ribeiro (2020) states a great point that we need to reality check and see the consequences of our righteousness coming from a place of power. We are all born into a system that is composed of values, traits, and behaviors. It is then up to us as group leaders to push those boundaries while also understanding ourselves inside our comfort-zones. One individual’s experience does not equate to others, and vice versa. We must be careful not to diminish the hardships of others who come from different walks of life. I can be as competent as possible however, that does not change the situations and oppression that a person feels outside of the group (Ribeiro, 2020). At the end of the day, I am still a White person who experiences privilege, and in this setting, it is up to me to take a step back and learn from my clients. It is okay to feel uncomfortable especially when your privilege harms another individual’s way of life. Stepping out of one’s comfort zone, from my perspective, to not only teach your clients but also learn from them will create a more dynamic, interesting, and meaningful alliance. It brings down the boundary of leader and client and focuses on building trust through understanding.
People feel inclined to ubiquitously support those who are within their “in groups,” while not understanding the group that they may identify as the “out-group.” This can lead to hostile dynamics and the transmission of microaggressions. What I propose is that we require a diversity guideline before entering a group. This could be a written document reminding group members that individuals come from all different walks of life and to respect their experiences. This will enable individuals to become cognizant of the context of their struggle or establish within themselves a place of privilege to acknowledge when discussing with others. Lefforge and others have proposed a new training model that consists of “didactic training, role-play and modeling, and an experimental fishbowl-style group exercise,” (2019). The model is meant to address microaggression and replicate the external stressors outside of the group on a smaller scope. By putting these aggressions under a magnifying lens, it allows these issues to become salient. It shows others in the group a taste of what someone with different factors of marginalization go through on a daily basis. This modality was received well with multiple conferences associated with the American Group Psychotherapy Association. Many people are very sheltered in their viewpoints and are simply ignorant to the struggles around them. For example, I am a white cis female. As a woman, I am faced with the structural boundaries that come with being femme- presenting. However, I won’t be able to fully put myself in the shoes of a woman of color. There are more barriers put in place in society as an individual of color.
I do, however, note to be sensitive as I was trained to have this open exploration into my own privilege and biases. As important as it is for me to keep myself in check, I believe that it is as important for others in a group to be sensitive and come with an open mind. As DeLucia-Waack (2010) explains, there needs to be recognition and understanding of other cultures in group settings. Most group practices, and therapy tactics in general, are formulated around a Euro-centric model. This places individuality and self-expression on a pedestal, which inherently contradicts many other cultures that are raised collectivist with different moral values. DeLucia- Waack emphasizes that in addition to us as group leaders and facilitators being trained in having cultural competency, it is as important for a group to understand the values and intricacies of each other’s backgrounds (2010). This is to minimize microaggressions, encourage discourse, and create a much more welcoming and open environment for everyone. Previously, I have mentioned how a misinterpretation can lead to misunderstanding, as well as unnecessary shaming in the microsystem that is group therapy. The last thing you want as a group leader is to make someone feel uncomfortable and unheard. As much as we like to think that we are a melting pot of people, we are oftentimes unaware of the cultural nuances that different people experience that may interplay in interactions. One person being quiet can be representative of either being shy and reserved, or it can also represent being respectful based on how they were raised. Groups that are the most effective are the ones that try to understand their position as an individual, as well as their peers’ thoughts through a cultural lens. Cultural spans beyond just ethnicity or nationality; it covers behavior, views on individuality, problem solving, views on the world, as well as coping styles (DeLucia- Waack, 2010). In my culture, being a Russian Jewish woman, it is encouraged for us to speak up when we are unhappy, but only if our source of unhappiness is outside of our families. We are taught to have the utmost respect for our elders and take their word as golden. I as a group leader may also bring my own viewpoints inadvertently when trying to facilitate discussions, however, I must be self-reflective and keep track of my own biases.
It might also be beneficial, in addition to some sort of diversity training, to have resources readily available for group members to study. Oftentimes I have noticed, people are simply unaware of cultural differences due to being surrounded by the same type of people. For instance, let’s look at a hypothetical white cis-hetero male who grew up in an upper-class white neighborhood. Perhaps his school consisted of a diverse group of individuals. Maybe he watched movies, shows, or listened to music from all around the world. He may have had interactions with people of different cultures, but due to his environment, it could have been very limited. How much he was entrenched and aware of the oppressions faced by people who are unlike him were most likely restricted. All that he knows and all that he has experienced came from a place of privilege. The place of power has restricted how keen he may have been on strife’s that did not impact him directly. He did not experience the same oppressions that other marginalized groups did. It doesn’t help that the education system follows a historical background that is written by White individuals, so the background of what they are learning is already skewed and comes from a place of power. History is written by those who already have control. These biases and assumptions are based on stereotypes or a rigidity in viewpoints due to lack of multi-ethnic experiences. By providing a list of resources about cultural competency when creating a group might start turning the gears a bit into thoughtful discussions that are open-minded and free of judgment. Beyond that, it can be a conversation point to bring up during meetings and share thoughts on what they felt as they read through the resources. The Association for Specialists in Group Work (ASGW) states that there are various ways in which group leaders should adapt to their group, while also continuing acquiring knowledge. This can be used to monitor the group’s growth throughout the weeks. The list of resources available can be proactive for group growth and cohesion.
In conclusion, bonding over experiences is very real and makes us bring a sense of empathy that is unmatched to someone who has not been through similar experiences. From a personal standpoint, I feel more connected with other women or other children of immigrants, since we could have had similar upbringings and struggles. Choosing to disclose personal information, especially in a group setting with new people, is daunting and scary. It is exemplified if you are someone who feels like they don’t belong in a group of people who are the same group that ostracize you in the outside world. It is important to acknowledge your standing in their eyes, while also listening and being active learners.
References:
DeLucia-Waack, J. (2010). Diversity in groups. In R. K. Conyne (Ed.), The Oxford handbook of group counseling (pp. 83–101). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780195394450.013.0006
DeLucia-Waack., J. L., Donigian, J. (2004). The practice of multicultural group work: Visions and perspectives from the field. Wadsworth Press
Lefforge, N. L., Mclaughlin, S., Goates-Jones, M., & Mejia, C. (2019). A Training Model for Addressing Microaggressions in Group Psychotherapy. International Journal of Group Psychotherapy, 70(1), 1–28. https://doi.org/10.1080/00207284.2019.1680989
PsychotherapyNet. (2009). Irvin Yalom Outpatient Group Psychotherapy Video. [Video]. https://www.youtube.com/watch?v=PwnfWMNbg48&ab_channel=PsychotherapyNet
Ribiero (2020) Examining Social Identities and Diversity Issues in Group Therapy: Knocking at the Boundaries. Routledge Press.
Yalom, I.D., & Leszcz, M. (2020). The Theory and Practice of Group Psychotherapy (Fifth Edition). Basic Books. 56-57
From the Inside Out: Psychology Trainees’ Experience of a T-group.
Flanagan, M., & Williams, M.
Abstract
The advent of T groups began over half a century ago as research on group dynamics began illuminating the importance of focusing on the here and now in a group setting (Highhouse, 2002). These groups consisted of 10-20 members meeting consistently over several weeks, concentrating on the relationships among members and how the group functions as a whole (Bradford et al., 1964). The popularity of these groups has since waned; however, a wealth of information can still be gained from a participant in a T group. The benefit is especially relevant for graduate students in training to become clinical psychologists and practice group psychotherapy in some capacity.
Introduction
It is commonplace for psychology trainees to be required or advised to be in therapy during their training program in order to understand better what it is like to be a client in therapy. Not many students, however, get the chance to encounter what it is like to be in a group therapy setting. Nine students and myself were afforded the opportunity to immerse ourselves in a T-group process led by our professor, and it was an invaluable training experience that will forever impact the group work I do as a Clinical Psychologist.
Traditionally, a T-group is focused on individual self-discovery and growth (Gorden, 1979). It has very little structure, and in a setting of silence and few-to-no instructions, the group members begin the discourse. The warm and kind professor we had grown accustomed to receiving copious amounts of lecture material from was, in this setting, silent and still faced. All that we were told was the time for the T-group, how to set up the room, and “to discuss the material of your last four or more classes and to observe and reflect on the group process as you do so” (Scrofani, 2022). The group took place over five weeks in one of our classrooms, facing each other in a circle of chairs. We would start in silence until a comment from a group member punctuated it. Then we were off. To understand our group better, it may help to know a little about the history of T groups.
History of T Groups
The T group, or “training group” has its conceptual beginnings through connections to the Tavistock clinic and psychologists such as Eric Trist and W. R. Bion where group therapy dynamics and techniques were being investigated in the 1940s (Highhouse, 2002). In 1946, the idea for a T group arose from Ronald Lippitt, Leland Bradford, and Kenneth Benne leading a group with Kurt Lewin where students were allowed into process observations by the research observers of the student group discussions. The students were supplied new insights into their and the group’s behavior from the perspective of the research observers. Following the creation of the National Training Laboratory (NTL) for group development in 1947, T groups began evolving into a clearer configuration by focusing on the here and now, or what was happening in the group and its members (Highhouse, 2002).
According to Bradford et al. (1964) the group would be made up of 10-20 members that would meet for 2-3 weeks several times per day. It is important to note that the trainer who was part of the group was not a group leader. The groups would often start with a trainer sharing a statement about focusing on the here and now and that the work of the group was up to the group itself but would provide no further instruction. The unstructured nature of the group often led members to come up with a task to turn their focus on. The task could be anything from having members introduce themselves or simply discourse about their thoughts about the group. Throughout the group, the trainer would share an observation of the group process or a certain individual in order to keep the group focused on the here and now (Highhouse, 2002).
A Personal Experience of a T-group
To say we floundered for the first two weeks is an understatement. We struggled with knowing what roles to assume and rules to follow. How could we deal with such ambiguity? Positive and negative feelings emerged. Long, awkward silences. And moments where individuals violated the silence in an attempt to get a dialogue started. We were tasked to do work, but at the beginning, few of us, if any, fully understood what that meant. Our professor noted in a lecture that pure group process “is difficult and threatening, but extremely valuable” (Scrofani, 2022). How quickly we forgot these words of wisdom and reassurance when we were amid the pure group process experience.
Occasionally our professor would break his seemingly lofty silence to offer brief insight or direction. Oh, how frustrated we were with him! Why could he not just tell us what to do, what to talk about? Slowly, however, we began to make progress. Ruptures between individuals were explored, and we arrived at insights on our own. Soon, our professor’s comments no longer derailed or antagonized us but confirmed the work we were already doing.
As I delved deeper into this short term-group experience, I found that while there was relief at no longer having to encounter such raw emotion, a part of me would miss it. Getting to experience my cohort mates in such an unadulterated way showed me just how little I knew about them, and they knew about me and made us reflect on our own feelings toward the individuals sitting next to us. It was fitting, but also that much harder, that there were several members who were leaving the program at the end of the semester.
Reflecting back, we experienced several curative factors of group process in real-time. Yalom and Leszcz (2020) described the change within a group as being motivated by discomfort, which was very true for us. The few of us who broke the silence perhaps did so because we were uncomfortable with it. Yet, we also witnessed another factor proposed by our professor. We internalized the good we found in each other which also facilitated change within the group (Scrofani, 2022).
For example, I initially hesitated to offer my insights, waiting for bolder members to speak up first. Then one session, I voiced my thoughts and broke the silence. I wanted to know what it felt like to be the first to say something, so I channeled what I saw as leadership from other members and took a step into the abyss. I internalized this good in the group, and in doing so, I realized that I liked sharing my thoughts, and others responded positively to what I had to say. Gradually, I began speaking more and responding to other members with affirmation.
From another perspective a colleague reported internalizing this exercise. This interpretation of the exercise encouraged one to experience the group process and embrace relationships with the cohort. This goal was the motivator to speak up and begin a dialogue. Although noteworthy in beginning the intra-group process at other times it revealed ruptures.
The ruptures that occurred were repaired through compassion; the hurt that was expressed was healed through affirmation. For example, one week, we spent the entire group attending to the feelings experienced by individuals who had not felt included in cohort social gatherings. The rupture was addressed through the recognition of how these cohort members had indeed been left out at no fault of their own. We acknowledged our differences and reflected on what was occurring in the here and now, namely hurt and guilt, which, as Yalom and Leszcz (2020) noted, increased the group’s power and effectiveness.
Summary
We recognize several limitations of my reflection on group process. Our overall positive experience was dependent on several protective factors, which may have drastically changed the group if they had not been present. The members of our group had been colleagues for two years before completing this exercise, and while there was anxiety about the exercise, the anxiety would have been much more intense had we been strangers. Additionally, we belong to a training program whose core values are that of respect and compassion for the human person, and it is likely that these values influenced our interactions. Another factor that affected our ability to engage in the group, was a priming effect created by attending lectures throughout the semester on group process prior to beginning the exercise. We knew and felt safe with the professor who became the trainer. Our professor is also a highly experienced group clinician. Had he been an outside or more inexperienced group clinician, we may have had a very different experience.
In the end, the lesson reinforced was that you really don’t know what it’s like to be in the client’s shoes unless you do it yourself. You feel the pressure to speak, to not speak, to call someone out for not sharing, to put someone down for taking too much attention. The best and the worst of you creep up and feel exposed. How can someone run a group without having the experiential knowledge of what it feels like? For our part, we are indebted to this experience and will keep in mind all that we felt and learned when we are leading groups ourselves.
References:
Bradford, L. P., Gibb, Benne, J. R., & Benne, K. D. (1964). T-Group theory & laboratory method. New York, NY: John Wiley & Sons.
Gorden, W. I. (1979). Experiential training: a comparison of t-groups, tavistock, and est. Communication Education, 28(1), 39–48. https://doi.org/10.1080/03634527909378328
Highhouse, S. (2002). A history of the T-group and its early applications in management development. Group Dynamics: Theory, Research, and Practice, 6(4), 277–290. https://doi.org/10.1037/1089-2699.6.4.277
Scrofani, P. (2022). Lecture material from PSY 820: Group Psychotherapy. The Institute for the Psychological Sciences at Divine Mercy University: Sterling, VA.
Yalom, I. D., & Leszcz, M. (2020). The theory and practice of group psychotherapy (6th ed.). Basic Books/Hachette Book Group.
Reflections on Queerness, Age, and Self-Disclosure in Inpatient PTSD Groups
John Stitt
johnstitt@gwu.edu
The George Washington University
Abstract
Group leader self-disclosure’s impact on group psychotherapy is an area of discussion that can benefit from further exploration. Self-disclosure of held identities by the group leader is an important consideration in group research. I hope to add my voice to the discussion as a group leader in training who has had a variety of group experiences with self-disclosure of held identities. The aim of this reflection is to add my voice through conveying my experience as a group leader in training and various impacts of my self-disclosure of identities. In this discussion, I hope to include analysis of the factors that influence how identity self-disclosure are taken up both from an individual and structural standpoint. This also opened productive discussion about authority, others’ experiences of me, and my beginning to bring myself into my work. Ultimately, I have found that bringing in group leader identities can generate productive discussions about difference, authority, and increase insight for those in group therapy settings.
Conversations about being a queer individual therapist and self-disclosing about sexual orientation are happening in the literature (Cabai, 1996 & McPherson, 2019). However, conversations around the impacts of the self-disclosure of held identities of group leaders are still a relatively new area in group therapy research, especially as it relates to queer identities.
I hope to contribute to this discourse in my graduate school career engaging in further learning about group processes by reflecting on my experience as a queer group leader. My first group experiences came from working at a residential trauma treatment center during my undergraduate career. At this facility, I was a residential technician, and my responsibilities consisted of upholding rules, coordinating weekend recreation and service activities, and leading skill-building and psycho-educational groups. This range of responsibilities required me to negotiate various roles in managing these various tasks. I pursued this job because I was interested in entering the field and learning more about therapy work. In this position, I was able to get an incredible depth and breadth of experience – because the program was short-term treatment (35-45 days) there was a decent amount of turnover, with approximately two new clients entering the house each week, with a maximum capacity of 15 clients with severe trauma histories. Groups were integrated with several different trauma-focused treatment modalities. This meant I was able to work with many people and experience varied reactions to my held identities. These reactions were informed by the client’s lived experiences, their held identities, and learned preconceptions. The patients were generally (but not exclusively) middle-aged, white, heterosexual, cisgender men, and mostly first-responders or veterans. I am a younger, white, and (open and visible) queer person. Because of this, I found that the group work was a microcosm of the outside world in which there were people of various diverse backgrounds engaging with those in treatment. This paper will explore, through the use of personal narratives, some of the many complexities of being a gender and/or sexual minority group leader.
My responsibilities in this role included performing typical residential technician duties, as well as organizing and leading weekend recreation and service group activities. In this capacity, I also was able to lead skill-building and psychoeducation groups weekly. I was also given the opportunity to sit in on some processing groups led by clinicians at this center. Upon entering this position, one of the first things I noticed was several clients used to a very patriarchal authority structure (i.e., those coming from a place where age and masculinity were markers of status/respect) had difficulty with me when I was in an authority or leadership role. This came about especially when I was required to hold firm boundaries with group members. Some instances of this included when I would organize activities with mandatory attendance, uphold house rules about TV and movie times, and maintain smoking time frames. Some of the clients were able to name that they had trouble with someone who was young and “different” from them in an authority role because it departed from the leadership structure they were used to (where masculinity and age were both essential markers of leadership). My difference also created room for growth by troubling preconceived ideas about leadership and building relationships that served to shift perspectives. Challenging these ideas of who “should” be leading was difficult for many clients to cope with, and they opened up discussions about why the clients felt like I should not be maintaining boundaries with them. In this same vein, my authority forced people to grapple with their deeply held personal beliefs about power and sexual orientation (in the context of the United States being a heterosexist society) which impacted the way they moved through the world. These deeply entrenched beliefs typically came out through pushback when I had to maintain a boundary. Through maintaining strong relationships with these clients and compassionately communicating and holding boundaries, I was able to increase flexibility around these deeply held beliefs. It was also interesting to hear the associations people had with my leadership role – some members said that I reminded them of their children, others of a boss they didn’t like, and one of a parent. Through this transference, they were able to work on why they had difficulty with people and to realize their projections were not always accurate.
I also found many people used my identities as a bridge to try and relate to me through a projected experience of “not fitting in” or “not being understood”. Clients expressed that having the fantasy that I held the same feelings they did about others in their lives allowed them to feel connected and understood by me. Using their fantasies allowed for a greater understanding of their assumptions and desires in interpersonal relationships. These client perceptions of my queer identity also informed their belief that I had experienced difficult things in life. While I did not self-disclose my history to them, being able to hear their assumptions about me, based on my identities, served to help facilitate my understanding of their perception of others and the world around them.
During my tenure in this role, I found self-disclosure was something that both helped and hindered the group, depending on the nature of the disclosure. I also found that when I self-disclosed, I had to be comfortable with that information being shared with all members of the group. Many people asked my age – and initially, I was forthcoming. For most, this was used as a non-ambiguous way to locate me in the world. However, I found that self-disclosure without discussing the implications, fantasies, and assumptions of what it would mean to know that aspect of my identity would foreclose productive conversations that could help these clients know themselves better, such as the client who found out I was the same age as their child and began to express resistance to me about following set rules. Further in their treatment, this client was able to connect the dots about the reason they struggled with me being an authority figure due to my age.
I was able to foster curiosity with the clients when I asked them what they hoped to understand about me based on my sexual orientation or age. I also often got the sense that the way I was perceived was more consciously about my age, but it was also about my sexuality but on a less conscious or open way. By that, I mean that the impression I was frequently left with was that my age and sexual orientation (and gender presentation) were bound together in the minds of many I was working with. A potential factor in this is there is a generational difference in social acceptability with discussing age compared to sexual orientation. Due to heteronormative attitudes and beliefs, sexual orientation was viewed as unspeakable or unnamable. Additionally, the language I have learned to use to explore gender, identity expressions, and sexuality is vastly different from that of people who are not as familiar with working with the complexities of the LGBTQ+ community (Rossi & Lopez, 2017).
Despite the occasional difficulties that I faced navigating my identities and self-disclosures, there were also touching moments that occurred in the group. For example, there was a moment when my held identities allowed someone to use their perception of me to understand their relationship with another. A client told me that she had a queer child who she had had a difficult time understanding. She said that getting to know me had allowed her to better understand how she related to LGBT people in her life outside treatment. She was able to sit in the tension between her strongly held homophobia, understand the impact that her actions had on her child, and work on repairing that relationship.
On the other hand, when microaggressions (or overt aggressions) were enacted by group members, my queer identity served to open up those conversations about the impacts of words and actions. My identities (especially age and LGBT identities) served to bring the real world into the group and help the group negotiate their behaviors in the context of belonging to a diverse human community. It helped the group express conflicts within the group and improve people’s experience of interpersonal interaction in the real world. One such example of this is when a new group member made a homophobic joke that I didn’t hear. The other group members addressed it with him directly and immediately. I later learned that the group members encouraged him to think about what he was saying not just for my sake but for the sake of everyone who may be in the room and made uncomfortable by insensitive jokes. They were able to use my identities not only to give a concrete example of how his actions could be hurtful but also to help him mentalize the impact of his words on a community that may have generally been more abstract for him. Ultimately, it also allowed other members of the house to explore their feeling toward a new member of the group.
Being a queer leader also required me to explore and deal with my own feelings that came up around the people I was working with. When we would get an LGBTQ+ client, I had to be aware of what their identities pulled from me, while noticing my reactions. I was also confronted with dealing with (primarily white) masculine ideals in ways that I was not used to. There were difficult aspects of this work that required me to have compassion in moments where privilege was salient. The most intense example of this was when a client was saying homophobic slurs (not directed towards anyone in the room) and I had to talk with him about why this was not allowed while maintaining my composure.
Through this group experience, I was able to develop close relationships with people that I did not usually get the chance to interact with and learn from. I gained an understanding of how to navigate complicated power dynamics with those in the group involved in the process. It was not always easy – giving and receiving feedback was something that we all learned to accept. I had to work with others to find out how our various positionalities to power informed how we interacted with and experienced each other.
Summary
The reason I feel naming, addressing, and understanding how my identities impacted the group working space is beneficial is because I think group leader diversity is an important consideration. Identity differences are helpful, especially when these factors can help others become more aware and able to integrate varied perspectives. Discussing difference also opened up conversations around a number of factors that influence treatment, including interpersonal interactions, relation to authority, and cultural assumptions. I found that engaging with differences allowed many people to come up with different reactions and associations that could help them on their healing journey. I was also able to learn about the nuances and varied reactions that come from self-disclosure as well as begin to think about how relation to power influences others’ reactions to my self disclosures. This experience further provided me the opportunity to understand the ways I took up reactions to my self-disclosure as I began to navigate bringing myself into my work. Additionally, our changing world demands adaptation of group therapy to evolving cultural norms (Chen, Kakkad, & Balzano, 2008). Group therapy’s adjustment to new ways of thinking, especially when informed by the advancing understanding of gender and sexual minorities, will serve to keep groups (and group leaders) rooted in a more socially just world.
References
Cabaj, R. P. (1996). Sexual orientation of the therapist. In R. P. Cabaj & T. S. Stein (Eds.), Textbook of homosexuality and mental health (pp. 513–524). American Psychiatric Association.
Chen, E.C., Kakkad, D. and Balzano, J. (2008), Multicultural competence and evidence-based practice in group therapy. J. Clin. Psychol., 64: 1261-1278. https://doi.org/10.1002/jclp.20533
McPherson, AS. Client-initiated disclosure of psychotherapists’ sexual orientation: A narrative inquiry. Couns Psychother Res. 2020; 20: 365– 377. https://doi.org/10.1002/capr.12274
Rossi, A. L., & Lopez, E. J. (2017). Contextualizing competence: Language and LGBT-based competency in Health Care. Journal of Homosexuality, 64(10), 1330–1349. https://doi.org/10.1080/00918369.2017.1321361
The Group Psychologist Spring Issue 2023 Pre-Doc Forum
Article Review 1 Women’s Action for Resilience and Empowerment (AWARE)
Irene Kaggal, B.S.
George Washington School of Professional Psychology- Group Psychotherapy
Lipson et al. (2018) noted the unfortunate reality that Asian Americans, especially college-attending Asian American females, are prone to mental health problems, such as depression, anxiety, and PTSD symptoms based on multicultural stress and systemic oppression. Furthermore, due to the fact that culturally-based psychotherapy interventions geared for Asian American women are limited, many Asian American females do not seek mental health services, in general. Recently, Hahm et al. (2017) developed a group psychotherapy intervention program called Asian Women’s Action for Resilience and Empowerment (AWARE) to speak to the mental health needs of Asian American women. AWARE was created to specifically target depression, anxiety, and Post Traumatic Stress Disorder (PTSD) symptoms faced by Asian American women. Essentially, the Asian American women in this particular group psychotherapy intervention attend 8 weekly in-person sessions that are approximately 90 minutes long. After their session, these women receive a daily text reinforcing what they learned during the day’s session.
Hahm et al. (2022) conducted a two-fold study to examine whether or not AWARE could successfully be utilized in university settings and if AWARE could help reduce group members’ depression, anxiety, and PTSD symptoms. Forty-four Asian American females between the ages of 18-35 participated in AWARE sessions across three universities in Massachusetts, led by female Asian American group therapists at their respective universities. The measurements included a modified version of the Seeking Safety rating scale to assess implementation fidelity over the course of therapy, the Center for Epidemiologic Studies Depression Scale (CES-D), Hospital Anxiety and Depression Scale-Anxiety (HADS-A), and the PTSD Checklist-Civilian version (PCL-C) to assess patients’ depression, anxiety, and PTSD symptoms, respectively, at the end of the program. It is important to name that the PTSD Checklist is a standardized self-report rating scale for PTSD comprising of 17 items that correspond to the key symptoms of PTSD and is based on the DSM-V criteria for PTSD. That being said, two versions of the PCL exist: the PCL-M, which is specific to PTSD caused by military experiences, and the PCL-C, which is useful to understand any traumatic event (Wilkins, Lang, & Norman, 2011). The PCL-C has been adapted for use in primary care or general medical settings, and has been used extensively with the Asian American women in this study.
Summary of Procedure & Findings
The researchers found that the member attendance rate across all three schools was at the 75% mark, which was statistically higher than most other group session attendance rates. In addition, therapists evaluated on the Seeking Safety modified Likert scale averaged at a score of 2, which is classified as good. Finally, group members’ depression, anxiety, and PTSD symptoms significantly decreased by the end of the intervention. As indicated by Table 1, the pre-post intervention comparison showed significant improvements for depression, anxiety, and PTSD symptoms. All clinical measures utilized in this study showcased reductions in depression, anxiety, and PTSD symptoms.
Table 1. Pre-post intervention clinical measures for AWARE participants across three colleges/universities
| School A | School B | School C | All Sites | ||||||
| Variables | Baseline Mean (SD) | Post-intervention Mean (SD) | Baseline Mean (SD) | Post-intervention Mean (SD) | Baseline Mean (SD) | Post-intervention Mean (SD) | Baseline Mean (SD) | Post-intervention Mean (SD) | Pre/Post Change Mean (SD) |
| CESD-R (Depression) | 35.8 (19.2) | 26.8 (20.7) | 25.7 (13.3) | 6.43 (3.78) | 19.2 (11.9) | 12.4 (8.17) | 26.2 (16.5) | 16.3 (15.5) | -9.95 (10.9) |
| HADS-A (Anxiety) | 13.6 (4.48) | 11.0 (4.58) | 12.0 (2.24) | 5.57 (2.88) | 11.1 (4.45) | 6.35 (2.69) | 12.1 (4.20) | 7.84 (4.15) | -4.30 (3.36) |
| PCL-C (PTSD) | 43.4 (13.8) | 39.2 (15.9) | 45.4 (9.50) | 26.1 (6.72) | 38.2 (10.3) | 29.8 (8.75) | 41.4 (11.6) | 32.4 (12.4) | -8.95 (11.5) |
Clinical implications & Limitations
The Hahm et al. (2022) study made contributions to the literature. The study was the first to showcase a group psychotherapy model that is culturally applicable for Asian American females. These findings are important because by utilizing AWARE in mental health service centers, young Asian American females will feel comfortable to seek out group psychotherapy to alleviate their mental health problems and learn new coping mechanisms. However, several limitations also exist. Hahm el al. recognized that this study had a small sample size, was non-randomized, and had no control group. Along with that, because the group members self-reported their symptoms after completing AWARE, there could have been social desirability bias. Finally, because the forty-four group members of this study were from three universities in Massachusetts, there is the issue of low generalizability. Their research inspires additional studies that are needed to explore AWARE and other types of group psychotherapy interventions that are culturally appropriate for Asian American females in broader settings and to evaluate how to prevent lapsing symptoms after the intervention is complete.
References
Hahm, H. C., Hsi, J. H., Petersen, J. M., Xu, J., Lee, E. A., Chen, S. H., & Liu, C. H. (2022). Preliminary efficacy of AWARE in college health service centers: A group psychotherapy intervention for Asian American women. Journal of American College Health, 70(3), 665-669. https://doi.org/10.1080/07448481.2020.1777135
Hahm, H. C., Chang, S. T. H., Lee, G. Y., Tagerman, M. D., Lee, C. S., Trentadue, M. P., & Hien, D. A. (2017). Asian Women’s Action for Resilience and Empowerment intervention: Stage I pilot study. Journal of Cross-Cultural Psychology, 48(10), 1537-1553. https://doi.org/10.1177/0022022117730815
Lipson, S. K., Kern, A., Eisenberg, D., & Breland-Noble, A. M. (2018). Mental health disparities among college students of color. Journal of Adolescent Health, 63(3), 348-356. https://doi.org/10.1016/j.jadohealth.2018.04.014
Wilkins, K. C., Lang, A. J., & Norman, S. B. (2011). Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depression and anxiety, 28(7), 596-606. https://doi.org/10.1002/da.20837
Research Review II
Article Review 2 Effectiveness of group v. individual trauma-focused treatment for PTSD in veterans
The importance of Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy in the individualized therapeutical setting has been known in treating Posttraumatic Stress Disorder (PTSD), but very few research studies have looked at the efficacy of group therapy in treating veterans with PTSD in the therapeutical setting (Foa & Rathbaum, 1998; Resick, Monson, & Chard, 2006). CPT focuses on tackling dysfunctional thinking by naming, actively challenging, and replacing these irrational thoughts with more realistic cognitions (Steenkamp, Litz, Hoge, & Marmar, 2015). PE encompasses in vivo exposure, psychoeducation, and the processing of fearful thoughts and emotions to overcome traumatic memories (Smith, Porter, Messina, Beyer, Defever, Foa, & Rauch, 2015). Smith, Porter, Messina, Beyer, Defever, Foa, and Rauch (2015) looked at the effectiveness of PE for PTSD in a veteran group and after 12 weeks of in vivo exposures within group sessions, significant reductions in PTSD and depression symptoms were noted. In the same spirit and to add to the literature, Spiller at al. (2022) explored the use of CPT group therapy in comparison to individualized CPT or PE therapy on the reduction of PTSD symptoms in veterans. In conducting this study, the researchers hoped to bring the potential benefits of group intervention to light and into a new avenue of symptom clusters. They retrospectively studied 6735 veterans who were discharged from the Veterans Affairs (VA) PTSD residential treatment facility between the beginning of October 2015 to the end of September 2020. Any veteran who was in need of inpatient treatment or was an imminent risk to self or others was not included in the study. Of those 6735 veterans, 2847 veterans received the group CPT intervention and 3888 veterans received the individual CPT/PE intervention. The measurements included a self-report for demographic purposes, Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) to assess anxiety and depression symptoms, respectively, and the PTSD Checklist for DSM-5 (PCL-5) to assess veterans’ PTSD symptoms at admission, discharge, and follow-up.
Summary of Procedure & Clinical Findings & Clinical Implications
The researchers found there to be a somewhat larger reduction in PTSD symptoms for veterans in individual CPT compared to the veterans in group CPT at the end of the interventions, but no statistical difference at the follow-up. There are a number of reasons why group CPT had slightly less of a difference in treatment efficacy when compared to individual CPT. Some of these reasons include type of treatment preference and stigma in addressing PTSD symptoms within a group. Nonetheless, this finding implies that both interventions produced comparable reductions in PTSD symptoms.
The Spiller et al. study made contributions to the literature. The study showcased that group psychotherapy does not have to necessarily be the second-line of defense in order to reduce PTSD symptoms. To elaborate, group psychotherapy can be paired up with either individual CPT or PE to bring upon clinically meaningful improvements. However, important limitations also exist. Since the study used a retrospective cohort design, the internal validity of the study was limited. Along with that, the researchers indicated having a higher rate of missing data in the individual CPT group compared to the group CPT intervention the follow-up, therefore, results should be regarded cautiously. In addition, the researchers noted that they were not privy to other types of interventions, such as psychopharmacological or secondary mental health treatments, that the veterans in both groups used during their time in the VA or after they were discharged. This could have led to residual confounds in interpreting the results. Finally, since the study did not include veterans with suicidal tendencies, the results cannot be generalized to include this particular group of veterans diagnosed with PTSD. All in all, future research needs to be conducted in order to establish whether group CPT can be a feasible treatment modality for veterans with PTSD in the VA.
References
Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. Guilford Press.
Resick, P. A., Monson, C. M., & Chard, K. M. (2006). Cognitive processing therapy: Veteran/military version. Clinical Psychology, 74, 898-907. http://www.alrest.org/pdf/CPT_Manual_-_Modified_for_PRRP(2).pdf
Smith, E. R., Porter, K. E., Messina, M. G., Beyer, J. A., Defever, M. E., Foa, E. B., & Rauch, S. A. (2015). Prolonged exposure for PTSD in a veteran group: A pilot effectiveness study. Journal of Anxiety Disorders, 30, 23-27. https://doi.org/10.1016/j.janxdis.2014.12.008
Spiller, T.R., Duek, O., Buta, E., Gross, G., Smith, N.B., & Harpaz-Rotem, I. (2022). Comparative effectiveness of group v. individual trauma-focused treatment for posttraumatic stress disorder in veterans. Psychological Medicine, 1-8. https://doi.org/10.1017/S0033291722001441
Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA, 314(5), 489-500. https://doi.org/10.1001/jama.2015.8370
A Sameness in Resistance: The Barriers to Leading and Participating in Group Therapy
Presley Scott
Professional Psychology Program, George Washington University
Abstract
The present article presents the supportive evidence for the effectiveness of Group Therapy and argues that there is a shared resistance among individual participants and group therapy leaders in participating in group therapy. Psychological resistances such as, social anxiety, fear of anger from other group members, dread of experiencing shame and humiliation, and desire for individual attention are explored and followed by practical and structural resistances, such as, lacking, a scarcity of referrals, financial incentives, and skepticism and lacking awareness of the benefits of group therapy in the field. Given such resistance, further research and innovations in training are necessary to better educate clinicians and potential group participants to ensure that more individuals can benefit from the positive gains and impact of group therapy.
Keywords: group therapy, leading group therapy, resistance to group therapy, shame
There is a growing body of evidence to support the effectiveness of group therapy (Burlingame & Jensen, 2017). In comparing 67 studies of individual and group therapy formats, no differences in rates of acceptance, dropout, remission, or improvement were found (Burlingame et al., 2016). Among many unique benefits, it is posited that group therapy invites individuals into a multitude of here and now relationships, enables members to observe and potentially change their relationship patterns, provides a space to receive feedback on attempted new ways of relating and being, supports the development of accountability for one’s actions, and reduces isolation and shame through sharing experiences in the supportive presence of others (Shay, 2021). Further, research consistently indicates that the most important predictor of outcome in therapy is the quality of relationship between the therapist and patient (Norcross, 2002). This relational quality is true of both individual and group therapies; however, group therapy more heavily relies upon the power of relationships due to its relational focus and context (Rutan, 2021). Further, Shechtman and Kiezel (2016) posit that some individuals prefer group therapy because they enjoy listening to others, appreciate not always being the center of therapeutic attention, desire to connect with others through shared experience, and find the format more affordable than other individual therapies.
Though the benefits are evidenced, both clinicians and individuals maintain some hesitance to engage in the work of group therapy, as either leaders or members (Shay, 2021). According to Shay (2021) the obstacles to participation in group therapy are noted to include:
- social anxiety,
- fear of anger from other group members,
- dread of experiencing shame or humiliation, and
- desire for individual attention
Shechtman and Kiezel (2016) add that patients may prefer individual therapy out of desire for a more intimate and individual relationship with the therapist, wherein they are the recipient of the provider’s full attention. Further, individuals are more likely to trust the confidentiality and nonjudgement of the therapist (Shechtman & Kiezel, 2016).
As a result, these hurdles impact both individuals who might be referred for group therapy and the clinicians, themselves, who might take on leading such groups. According to Shay’s (2021) investigation of these barriers to pursue group therapy seem to suggest a parallel process by which reluctance persists across both potential participants and leaders, reducing the access and uptake of the powerful benefits of group therapy. As a clinician in training, with an interest in taking on the work of leading groups and admittedly with trepidation, I will explore some of these resistances through the lens of my own experience.
Participants may, according to Shay (2021) avoid engaging in group therapy is that they wish to maintain the primary attention of the therapist, what individual therapy offers, and they find it difficult or even painful to share the attention of the therapist with others. Similarly, clinicians may face this very same experience, in which they fear losing their patient to another provider, which may lead them to avoid referring their own patients to group therapy. As an extern starting my clinical training, I have found myself at times seduced by the “fantasied blissful relationship of a maternal dyad,” (p. 72) that Alonso and Rutan speak of pervading our culture and consider what it might mean to share the lives of my patients with other practitioners (as cited by Shay, 2021). Further, this idea raised my interest in the ways in which early clinicians may also be reluctant to disperse their influence or power, by inviting a whole group of untrained individuals (i.e. the group participants) to speak into issues and challenges raised by the group members by offering shared experience or suggested approaches that have worked or them in the past. Such reluctance may be a result of a novice clinician’s desire to establish their own authority or therapeutic voice, or it may also be a result of competency concerns in the clinician’s self-perceived ability to navigate ruptures between group members. There is leader humility required in the task of watching other group members make the very interventions, or perhaps sometimes even better interventions, than we ourselves as clinicians might employ. In many ways, the group is an invitation for the disbursement of the therapeutic power from the therapist to the group members. It is important to know boundaries, as Shay (2021) notes, “it can be unsettling or depriving to have to share this position of prestige with others,” of sharing the gratification of being the central helpful figure in a patient’s life (p. 71). Both novice and seasoned clinicians need to be educated to appreciate the benefits offered by the group in providing a multitude of transferences and dynamic relational opportunities that create a rich environment for learning and growth.
Further, it is suggested that one of the most powerful deterrents to group therapy is the fear of shame and humiliation (Shay, 2021). This appears to be true for potential group participants, but also for potential leaders, who may fear being challenged, particularly in a group environment (Weber & Gans, 2003). As a clinician in training, my skin crawled before even entering my program at the thought of having to record sessions or potentially have live-observation. There is something profoundly vulnerable about the experience of sharing one’s clinical work, whether process notes, transcripts, or recording. The group inherently opens a microcosm of life in which the therapist’s work is suddenly made visible to many individuals all at once, the group participants and potential leaders & co-leaders, who are likely to display a myriad of different responses to the therapist’s approaches and interventions. The fear of judgment, rejection, or attack in front of the group is a shared experience for both leader and participant. Further, members of the group bring with them their own “needs, goals, and levels of attachment and emotional health,” that the therapist is tasked to attend to all at once (Shay, 2021, p. 73). The power of shame lies in its propensity towards hiding because in isolation, shame festers and grows. The group space can be an “antidote to shame,” (p.72) by providing a shared space for members to speak openly of their shame-embedded experiences and be accepted by others, who may share similar experiences and support them in processing, metabolizing, and integrating their experiences (Shay, 2021). This very opportunity is arguably not present in the same capacity within the confines of individual therapy, wherein clinicians don’t often provide self-disclosure of shared experiences of shame with their patients (Shay, 2021). Thus, the group provides a unique opportunity to be met with shared experience of the other that might powerfully reduce one’s shame and further, provides group leaders with an invitation to, “use their life experience, self-awareness, and countertransference to deeply attune and resonate with group members’ vulnerability” (Shay, 2021, p. 72). Weber and Gans (2003) suggest that patients’ resistance to addressing shame may best be overcome by group leaders, who are prepared and willing to acknowledge, tolerate, and work through their own shame. Such capacity for the group leader to persevere and resist their own fears of shame and humiliation require adequate professional support and training.
Beyond the psychological deterrents, there are also the practical and structural aspects that may prevent clinician’s from taking on group work, such as, lacking resources and space to host the group, a scarcity of referral sources, financial incentives, and skepticism or lacking confidence in the modality by colleagues or institutions (Shay, 2021). It is these obstacles that often lead clinicians interested in group therapy to pursue costly memberships and certificate programs within professional networks and organizations that prioritize and promote awareness of the specialty and, as Shay (2021) notes, “not simply [as] an adjunctive therapy to serve more patients at one time or to help patients pass time while waiting to access individual therapy” (p. 70). Given the apparent stigma and psychological and structural obstacles, the field must do a better job at prioritizing educational opportunities, supervision, and training in group therapy to expand access and breakdown misconceptions that group therapy is a secondary treatment. Normalizing and modeling the referral process, training beginning clinicians in how to evaluate the appropriateness of group therapy for individuals and providing a vernacular for how to promote group therapy and share its benefits with prospective and current patients should be a core part of training for new clinicians. I recall only one instance in which our program’s clinic proposed discussing groups openly with prospective patients and this happened to occur when our clinic was on a waitlist for individuals and there was a desire to offer something to such clients. This attitude promotes the idea that group therapy might be the appetizer that we offer in lieu of the entre, and I am made to wonder in what ways this impacts the formation of such groups, the amount of resistance patients bring into the group, and the retention of such groups.
Summary
The group therapy process is an important one that might unlock specific dimensions of support and healing for patients. Yalom (2020) posits that the group process begins with the instillation of hope, wherein hope emerges as patients witness change in others in the group with shared challenges and their experiences become more universal and serve as a point of connection rather than isolation. As the group has formed, members begin to test out the safety of the group and begin sharing and expressing emotions, which leads to both individual and group growth (Yalom & Leszcz, 2020). The final stage of the group includes a review of the progress and outcomes, acknowledging what worked and did not, and exploration of feelings related to the ending of the group (Yalom & Leszcz, 2020). Attitudes of skepticism, fear, and anticipated shame prevent many from accessing group therapy and experiencing such gains. It is important that we, as clinicians, maintain an open curiosity about our held biases that might prevent us from referring our patients to group or prevent us from engaging in leading groups, ourselves. We have an opportunity to use our knowledge, clinical judgement, and the research available to demystify the group therapy experience and invite others into it. As we begin to model an openness and curiosity towards group therapy, perhaps our patients too might do so.
References
Alonso, A., & Rutan, J. S. (1990). Common dilemmas in combined individual and group treatment. Group, 14(1), 5-12.
Burlingame, G. M., & Jensen, J. L. (2017). Small group process and outcome research highlights: A 25-year perspective. International Journal of Group Psychotherapy, 67(sup1), S194-S218.
Burlingame, G. M., Seebeck, J. D., Janis, R. A., Whitcomb, K. E., Barkowski, S., Rosendahl, J., & Strauss, B. (2016). Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: a 25-year meta-analytic perspective. Psychotherapy, 53(4), 446.
Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. Oxford University Press.
Rutan, J. S. (2021). Reasons for suggesting group psychotherapy to patients. American Journal of Psychotherapy, 74(2), 67-70.
Shechtman, Z., & Kiezel, A. (2016). Why do people prefer individual therapy over group therapy?. International Journal of Group Psychotherapy, 66(4), 571-591.
Shay, J. J. (2021). Terrified of group therapy: investigating obstacles to entering or leading groups. American Journal of Psychotherapy, 74(2), 71-75.
Weber, R. L., & Gans, J. S. (2003). The group therapist’s shame: A much undiscussed topic. International Journal of Group Psychotherapy, 53(4), 395-416.
Yalom, I. D., & Leszcz, M. (2020). The theory and practice of group psychotherapy. Basic Books.
Enacting Group Dynamics in Virtual Supervision: Oscillations between the Macro and Micro
Razzan Quran, MSc, MPsy
Abstract
This article explores the group dynamics of a 2020 cohort of doctoral students in the field of professional psychology. I will be reflecting on my experience as a member of this cohort and the ways macro-level (e.g., on the societal level) and structural realities of oppression and disempowerment, in addition to disavowed grief and anger, influenced and shaped micro-level (e.g., between individual and peer-level) interactions within the cohort. A case study demonstrating these levels of group interactions will be presented. I will also touch on how it relates to the parallel aspects in the patient and how it could have been used to facilitate clinical training and the personal growth of both students and faculty.
Keywords: Group Dynamics, Macro Group Processes, Micro Group Process, Graduate Program, Racial Dynamics.
Context
At the start of the academic year, there was a buzzing sensation in the air within the cohort and outside on the streets. Each student plugged their laptop and attended the first day of graduate school virtually. For some, the comforts of home helped cushion the jitters of first-day meetings, for others, the nagging sounds and intrusions of family members made it ever more difficult to land in the moment; a moment of indulging in the harvest of one’s hard work. For the international students, the uncertainty and instability of the geopolitical conditions implicating the pandemic border controls, made a precarious situation, ever more stringent and chaotic.
Beginning in the initial week of classes there was a notable excitement, watered down by an invisible tension. Was this tension competition? Fear? Adult anxiety attachment? The palpable sentiment in the new cohort was different, there was a sharpness and zeal to it, the kind that hovers over immense existential reckoning. One of our first semester courses was a class titled “Diversity.” The instructor shared her intention was to provide a space for deeper understanding of ways the structural contours and interacts with the intrapsychic (Layton & Leavy-Sperounis, 2020). This class allowed for the release of socio-political tensions related to the murder of George Floyd, and five months of quarantine life, but it also made us ever so aware of the pressure valve preventing us from unraveling. It provided a space for students to put language to experience that felt raw, unprocessed, and unnamable.
Despite the raging fire on the outside (literally since some of us were located in Washington, D.C. during the 2020 U.S. presidential elections and later January 6th insurrection), we were expected to continue work as usual. We joined with one another, with the scent of tear gas and burnt tires still fresh to some of us, from the Black Lives Matter protests and militarized police response. There was a unison escape into academia and professional training, that simulated a familiar return to a secure attachment. We clung to the familiar as the world felt ever more uncertain and mournful (Marmarosh, Forsyth, Strauss & Burlingame, 2020). In conversations with one another, mainly through messaging applications, we shared memes, jokes, and side comments about the world. Our desire for closeness and belonging was manifested in a multitude of ways. For some students, there was a clear desire for closeness, as they sent out messages and initiated conversations. Others lingered in a distant way sharing emojis and memes; they were able to be in the group while also maintaining a safe distance. The group was not yet cohesive; we were sharing virtual space, as we were carrying with us the embodied burden of a virus that is unseeable causing deaths, and the lingering stench of structural oppression.
Case Study
To explore the impact of group dynamics in this cohort, I will present a vignette from the first semester of our first year. The intention behind this vignette is to reflect the permeability of structural reality and apply group dynamics to understand how a supervision intervention led by white instructors left students of color feeling shamed and unseen. The vignette pertains to a required course titled “Case Conference.” The course is garnered through presenting recorded de-identified clinical material, allowing first year graduate students to reflect over what they are hearing, and they are asked to ascribe theory to moment-to-moment dyadic interactions. The instructors were two white identified clinicians, with over 10 years of clinical experience. Both instructors identified as white Jews, one was a cis-gender female who had been treating the patient for many years in her private practice and was sharing the video for educational purposes. The cohort was 30% international students, 50% students of color of various ethnic backgrounds, and 20% white identified students. The client was a bisexual, non-practicing protestant, cis-woman, who was also middle class. Her presenting problem pertained to depressive symptomology and trauma, and she appeared to function within the borderline level of personality functioning when under duress.
From the very beginning, there was a division amongst the GW cohort, relating to counter transferential feelings. For example, almost all the international students and students of color, shared countertransference of resentment, anger, and disgust that the patient was over-dependent on the therapist. They appeared to see the white patient as having too much privilege and feeling angry about her neediness. Secondly, almost all of the white-identifying students, on the other hand, shared countertransference pertaining to sadness, longing, and helplessness.
During the case discussion, faculty’s initial response to students of colors’ counter transference was framed as a “lack of empathy toward the patient.” At one point, the client shared feelings of entitlement pertaining to her living condition in a rented apartment, to which students reflected associations with a “Karen.”[1] The students of color perceived the white patient to be entitled and did not recognize the patient’s suffering, and both instructors appeared uncomfortable staying with these negative reactions toward the patient in the class. Rather than explore these students’ associations and projections of the patient being privileged, the instructors encouraged them to reflect more deeply into their feelings in a separate space outside of the classroom. This was the significant rupture because the white instructors were not open and curious about the legitimate reactions students of color were raising toward white people. The faculty did not see the white patient as a privileged “Karen,” so they denied this possibility could exist. For the students of color, the white faculty started to act like white people in society who immediately reject the rage, pain, and hurt associated with people who have suffered from oppression, systemic racism, and intergenerational trauma. Over time, the students who expressed powerful negative feelings towards this client, began to withdraw. They felt judged by their initial reactions and misunderstood.
The conversation was then taken up by majority white students, who thought through the client’s traumatic childhood experiences, locating her sense of passive aggression as a byproduct of her trauma history and disavowed aggression. These students were often lauded by faculty for their capacity to demonstrate “compassion” and “attunement” to the client’s underlying suffering beneath her angry behaviors in the session. Empathizing with “sadness underlying her entitlement/anger” was rewarded, but expressing anger and frustration was not. Increasingly, the silence of the students of color grew louder. It has been noted by Debiak (2007) that the possibility of utilizing group interventions in culturally competent ways, must be closely examined. Additionally, group dynamics can “easily replicate oppressive conditions in the larger society,” adding “therapists must pay special attention to the needs of individuals in the minority in a group” (Debiak, 2007, pp. 5–6). In many ways, the students of color needed the same empathy and attunement that the white students and faculty were generously giving the white patient. The students of color need the faculty to see beneath the surface of their negative perceptions of the patient, to the more painful underlying group dynamics plaguing the students of color all the time, lack of trust and safety they feel in society, in their program, and in this class. It was extremely painful for students of color to not receive the same empathy from the faculty or fellow students who were able to easily see the underlying pain in the white patient.
According to DiAngelo,(2016), white fragility is presented in the inability to tolerate and acknowledge the shame evoked by identifying with the normative hegemonic group. The faculty/leaders struggled to situate the rage and fear expressed by students of color in the group as coming from years of oppression, racism, discrimination, and injustice. White society often avoids reactions to oppression. Instead of welcoming these reactions of rage and anger that were projected onto the white patient and exploring them as legitimate, the faculty shamed students of color by focusing only on their lack of empathy. The faculty focused on the needs of the patient, and they missed an opportunity to address the needs of students of color, especially during a time where racism and hate surround them. From my point of view, rage, anger, grief, and fear that comes from coping daily with social injustice, discrimination, and oppression was influencing the perception of the patient, fellow students, and the faculty.
As the semester progressed, the faculty became aware of students of color withdrawing from participation and asked people to share their honest reactions. However, the group space at this point had become mired for enacting macro-level processes, producing an unhabitable space to pick up this question without worrying of retaliation. As a result, using the private messaging feature on the Zoom application, I was witness to side conversations, in which students of color began to conceptualize the client away from the gaze of the instructors. Consequently, students of color were finding a safer way to express themselves avoiding moving away from the primary medium of discussion. Because the group was not safe and the members could not trust the white leaders, they needed to find a safer way to express themselves. Subsequently the group was having a powerful impact on my own sense of safety.
This experience brought revelations around the growing silence I was seeing on the streets. As I walked the streets of Washington D.C., I ran into Black Lives Matter sign after sign, but I wondered if I could trust them, similar to my uncertainty of trusting the white faculty and students. I wondered about the people behind the walls; were they virtue signaling? Was this a protection of their property? Or was there a shift happening, ever so incrementally in a collective reckoning with the years of enslaved labor and cultural erasure? I was not sure who I could trust.
According to Gitterman (2018) “when members of the larger social group are less secure about aspects of their identity, such as in high school or college settings, certain differences can threaten members’ emerging and fragile self-concept, thus leading to greater exclusion” (pp. 103). In this way, many students of color, insecure in their new role as a doctoral student, attempted to express their laden affect pertaining to the client’s presentation. They were taking a risk by expressing their honest thoughts & feelings about the patient. They were not aware of the underlying group dynamics emerging when they “walked” into the classroom led by two white instructors. The white faculty were not considering the underlying dynamics that could play out when students watched the case presentation and started to discuss it. The group dynamics were influencing everything, but no one was aware of any of it.
Reflecting now, I do not know how much was related to the client directly, and whether my cohort was commenting on the salience of holding space to process white fragility, in a world that felt unstable, uncertain, and fearful. It was a rupture in the group caused by the faculty/leaders, who unbeknownst to them, were ignorant to the fear, rage, and confusion experienced by the students of color when they heard a white woman complaining about her experience to another white woman. Many of the students of color had strong negative reactions that expressed a larger issue in society. How could they not be activated by seeing a white patient complaining and entitled.
The white students, on the other hand, were students who did not experience the same systemic discrimination, hatred, and oppression, and they were not triggered by two white faculty evaluating them or watching two white women engage in psychotherapy. The white faculty and students, with their white privilege, were not aware of the group dynamics influencing the entire group/classroom experience. The faculty filtered students of color as non-empathic, and were focused on protecting the patient from the negative projections. This, maybe, related to the faculty’s own denial and white privilege, to protect the patient with a history of trauma and abuse. But these two group leaders missed an opportunity to be empathic with the students of color. The students of color were shamed when leaders used the term “unempathetic” and asked them to “reflect deeper on your own,” it led to withdrawal, silencing, and a lack of space to talk and engage in repair.
As Marmarosh (2022), Debiak (2007), and Ribeiro (2020) all emphasize: the group space can very much activate and repair structural and systematic wounding. However, the group space must be approached with a cognizance, a curiosity, and a critical pedagogy willing to tolerate fragility, ambiguity, and the righteous rage that has long been disavowed. The group space could have been utilized in a more curious way, by not foreclosing the students’ countertransference as shameful. When students felt embarrassed, they recoiled. Possibly, if the leaders could have opened the space to name and identify the students’ feelings as a reaction and response to white fragility, they may have felt witnessed and understood, expanding space for deeper insight and self-awareness into their countertransference and what was coming up. The alternative space engendered in the “Diversity” class, became a place in which students of color learned the term “white fragility” and the vestiges it holds. In one way, the ruptures in one group space, were repaired in an alternative space. However, this has not given chance for both the instructors/leaders of the original course and the students to repair the confusion, erasures, and hurt feelings.
I am currently completing my third year in this graduate program, and I have noticed how time has healed some of these wounds, while also worked to maintain walls of difference. I write this, with the hope that we create and expand spaces of critical reflection, so we not only encourage but model to students how we can engage in what is happening “out there” by bringing it “in here.” I have learned that whether we like to acknowledge it or not, our groups are always in the room.
References
Debiak, D. (2007). Attending to Diversity in Group Psychotherapy: An Ethical Imperative. International Journal of Group Psychotherapy, 57(1), 1–12. https://doi.org/10.1521/ijgp.2007.57.1.1
DiAngelo, R. (2016). White fragility. Counterpoints, 497, 245-253.
Lang, C. (2020, July 6). How the Karen Meme confronts history of white womanhood. Time. Retrieved October 4, 2022, from https://time.com/5857023/karen-meme-history-meaning/
Layton, L., & Leavy-Sperounis, M. (2020). Toward a social psychoanalysis: Culture, character, and normative unconscious processes. Routledge.
Marmarosh, C. L. (2022). Attachments, trauma, and COVID-19: Implications for leaders, groups, and social justice. Group Dynamics: Theory, Research, and Practice, 26(2), 85.
Marmarosh, C. L., Forsyth, D. R., Strauss, B., & Burlingame, G. M. (2020). The psychology of the COVID-19 pandemic: A group-level perspective. Group Dynamics: Theory, Research, and Practice, 24(3), 122.
Paul Gitterman (2019) Social Identities, Power, and Privilege: The Importance of Difference in Establishing Early Group Cohesion, International Journal of Group Psychotherapy, 69:1, 99-125
Ribiero (2020) Examining Social Identities and Diversity Issues in Group Therapy: Knocking at the Boundaries. Routledge Press.
WHO. (2020, December 22). Weekly Epidemiological Update – 22 December 2020. World Health Organization. Retrieved October 4, 2022, from https://www.who.int/publications/m/item/weekly-epidemiological-update—22-december-2020
[1] Karen is a popular term used to connote an entitled and demanding white woman (Lang, 2020).
The Group Psychologist Fall Issue 2022
Student Research Review & Articles
Research Review
Group Member’s sense of safety and visibility in group therapy
Yifei Du, MS, MExpArtsTherapy
George Washington School of Professional Psychology
Two research studies’ findings resonate with me deeply, given my own experience as an international graduate student living and studying in the United States for the first time. While it may seem that cultural concealment and feedback are two unrelated concepts, they both connect to a member’s sense of safety and visibility in a group. For example, a minority group member who conceals their cultural identity may receive less positive and negative feedback in group (which results in worse improvement), and they are likely to feel unseen. On the other hand, a minority group member may receive less positive feedback and more negative feedback (also leading to less improvement), and they are likely to feel unsafe and attacked in the group based on their identity. In both situations, the minority member may be more prone to hide their cultural self and experience to protect themselves from a negative group experience, which further stimulates an undesirable amount or negative feedback from the group (and less perceived improvement and positive group process). Thus, a vicious loop develops. The two research articles I will describe will support the need for effective strategies for group leaders to incorporate into their practice. By writing this review, I hope that more group leaders and educators will become aware of needs of diverse patients.
- Rigg, T., & Kivlighan, D. M. (2022). Examining between-group and within-group cultural concealment in group therapy. Professional Psychology: Research and Practice, 53(3), 244-252. DOI: https://doi.org/10.1037/pro0000458
With growing awareness and emphasis on multicultural encounters in the psychotherapy space, there has been a surge in the publication of multicultural theories and studies for both individual therapy and group therapy. Nevertheless, few studies investigated the phenomenon and effect of cultural concealment, i.e., clients’ avoidance or non-disclosure of their cultural selves and experiences in therapy (Drinane, et. al., 2018). In their research, Rigg and Kivlighan (2022) sought to explore the correlation between an individual member’s cultural concealment and the group’s cultural concealment norm on members’ perceptions of improvement, group cohesion, and a global therapeutic factor.
Summary of Research & Findings
The study collected data from 341 clients from 81 process groups at 14 university counseling centers. The Cultural Concealment Questionnaire, Patient Estimate of Improvement, Therapeutic Factor Inventory, and Group Entitativity Measure were utilized to measure participants’ cultural concealment degree, the estimate of the improvement in group therapy, perception of a global group therapeutic factor, and perception of group cohesion. Hierarchical linear modeling and sensitivity analyses were conducted for data analysis. The study findings showed that a group member’s cultural concealment in the group is negatively associated with their perceptions of improvement, group cohesion, and group processes. Furthermore, the group concealment norm was negatively associated with members’ perceptions of the group process, but not associated with members’ estimated improvement or group cohesion. However, no significant difference between group- and individual-level ratings of cultural concealment on clients’ perceptions of improvement and group process is observed. In addition to the original hypotheses, the statistical results also indicated that there are other factors, beyond cultural concealment, influence clients’ perceptions of improvement, group cohesion, and a global therapeutic factor.
Summary of Study Implications
The study indicated significant correlations between a group member’s cultural concealment and their perceived improvement, group cohesion, and group process. Therefore, it is important for group leaders to pay attention to potential cultural concealment among group members and to foster an inclusive group environment with space for members to explore their cultural selves and experiences. Several actions could be taken to achieve this group. First of all, it would be beneficial for group leaders to foster positive cultural norms early in the life of the group. Specifically, during the prescreening and preparation meetings, group leaders could talk about potential sharing of culture and respond to group members feelings and concerns. It is also recommended that group leaders set examples for their cultural humility and cultural comfort in the group. Moreover, when negative cultural processes are detected in the group, group leaders can interrupt, name what is happening, and protect group members from microaggressions. In addition, since cultural concealment could be easily missed in groups, group leaders may want to utilize questionnaires, such as Cultural Concealment Questionnaire, to gather data and identify these processes as they occur in group therapy. By using such measures and inviting members to revisit such conversation in the group process, members may perceive more cultural opportunities in the group.
Comments
It is interesting to note that only the first hypothesis – a group member’s individual cultural concealment would be negatively associated with their perceptions of improvement and group processes – is supported. Indeed, cultural concealment could be a highly private thing that neither group leaders nor other group members are aware of. For instance, in a group where the majority of the members identified as heterosexual, a group member who identified with homosexual orientation could feel terribly isolated and uneasy to express their cultural self and experience in the group. Others in the group, however, might not be aware of the circumstance and might even feel that the group is LGBTQ friendly. Therefore, group-level cultural concealment may not necessarily reflect each group member’s feelings or their estimate of improvement or perception of the group processes. Neither was a contextual effect supported. Only a client, themselves, know their cultural concealment the best, and group leaders should respect and validate their feelings, non-defensively, as the bottom line.
- Kivlighan, D. M., Ali, R. W., & Garrison, Y. L. (2020). Is there an optimal level of positive and negative feedback in group therapy? A response surface analysis. Psychotherapy, 57(2), 174–183. DOI: https://doi.org/10.1037/pst0000244
Feedback is considered an essential therapeutic intervention in various theoretical frameworks. In group therapy, feedback is a key tool to facilitate interpersonal learning, particularly in groups that focus on interpersonal processes. There are, however, few studies exploring examining the ideal amount of feedback, specifically positive and negative feedback, for client outcomes or personal growth. In their research, Kivlighan and his colleagues (2020) explored whether perceived congruent and high levels of positive and negative feedback among group members correlate with group members’ perception of group cohesion.
Summary of Procedure & Findings
The study recruited 168 participants from 10 university counseling centers that offered interpersonal process therapy groups. Participants perceived amount of feedback, group cohesion, and improvement were gathered by a two-item questionnaire, the Group Entitativity Measure (GEM) for group cohesiveness, and the Patient’s Estimate of Improvement, respectively. Polynomial regression and response surface analysis were conducted for data analysis. The results showed that participants perceived greater amounts of positive feedback compared with negative feedback, at 4.03 and 2.78 out of 5 respectively. Moreover, the average rating of cohesion and improvement among participants were at moderate levels. Among the four independent variables, significant between-group variances were observed for members’ perceptions of positive feedback, group cohesion, and improvement. Members’ perceptions of positive feedback were significantly related to members’ perceptions of group cohesion and improvement. Additionally, members perceived high group cohesion when their perceptions of positive and negative feedback are congruent and high. Nevertheless, when members perceived high positive feedback and low negative feedback, the perceived group cohesion is the highest. On the other hand, estimated improvement is at its highest when the perceived positive and negative feedback are congruent and high. The estimated improvement is also high when perceived positive feedback is high and negative feedback is low. However, estimated improvements are lowest when members’ perceptions of positive and negative feedback are congruent and low, or perceived positive feedback is low while negative feedback is high.
Summary of Clinical Implications
The research provided several clinical implications for group leaders. First and foremost, group leaders are recommended to work to create a group environment where group members can share both positive and negative feedback. For the best possible group cohesion and improvement, positive-negative and positive-negative-positive amount of feedback are advised. Group leaders may consider group preparation, including discussion on the role and benefit of both positive and negative feedback, model giving and receiving feedback, and establish norms regarding giving and receiving feedback early in the life of the group to help foster a feedback-encouraged environment. In addition, it would be beneficial to explore potential obstacles when little feedback is provided among the members.
Limitations of Research
This research provided a preliminary indication of the significance of having balanced and high amounts of positive and negative feedback or discrepant high positive feedback and low negative feedback in interpersonal process group therapy. So far as I am concerned, there are three things that need further consider. Firstly, the accuracy of participants’ perceptions could be influenced by individual biases since all of the data are self-reported perceptions. A group member who feels awkward receiving positive feedback, for instance, might perceive that more positive feedback was offered by other group members than actually occurred. As a result, there could be a discrepancy between the ideal level of feedback amount the group leaders intended to encourage, and the level of feedback group members actually felt they received. Secondly, as the paper noted, Stockton and Morran (1980) identified seven factors influencing the feedback process, namely sequence, sender characteristics, focus, timing, amount, receiver characteristics, and group atmosphere. The correlation between feedback and group cohesion and outcome could be impacted and complicated by each group factors listed above. Further investigation that takes these factors into account would therefore offer the matter more sophistication. Last but not least, group composition and group heterogeneity – including differences in age, culture, functioning level of group members, etc. – can also have an impact on the outcomes. In this study, participants are all undergraduate and graduate students who may present at a relatively high level of functioning. Would the same results be replicated in groups with more heterogeneity and/or consisting of members with lower functioning levels? It is hard to say. Therefore, a close look at group composition and group heterogeneity would also add more perspectives for clinical ramifications.
Running Group Therapy Without Training: My Experience As A Group Leader While Working As A Psychiatric Technician
By Cara Judkins, BS
George Washington School of Professional Psychology
Abstract
In 2018, the American Psychological Association (APA) recognized Group Psychotherapy and Group Psychology as specialties, which require specialized education and training. The definition of group therapy has expanded over time to include various models of therapeutic approaches. However, a comprehensive definition includes any group dynamic that is used for prevention, training, counseling or guidance (Barlow, 2018). Regardless of the setting, leading a therapy group involves experience in working with certain populations, repairing ruptures, assessing for microaggressions, and understanding that the group is a microcosm of the real world. The purpose of this brief report is to reflect on my experience working as a Psychiatric Technician with the responsibility of leading therapeutic groups on inpatient units without specialized education or training, and the implications that can have on patients and the group as a whole.
Before starting graduate school for my Doctorate in Clinical Psychology (Psy.D.), I worked as a Psychiatric Technician at a local inpatient mental health hospital where I gained experience working with adults, adolescents and elderly populations, all presenting with a diverse range of diagnoses. Despite this wide variety of presenting problems, personality styles, disorders and levels of organization, one job duty remained the same across house: leading group therapy sessions. Whether working as a technician on the day shift or night shift, the responsibility was the same—facilitating either an AM or PM group session. These sessions were shorter than the standard psychotherapy group session, usually lasting a maximum of one hour rather than the standard hour and a half psychotherapy group.
As Psychiatric Technicians, it was our job to provide a specific protocol for each patient attending the group session:
- Mood rating sheet- prompting the patient to (1) rate mood from 1-10 with 1 being the lowest and 10 the highest;
- list any personal goals for the day;
- list aspects of healing or personal growth the patient wished to improve on;
- list any resources the staff or hospital might provide for those goals; and
- list any comments, concerns or questions that needed to be addressed.
During onboarding, supervisors advised me that this sheet was a type of outline to follow that should help guide the patients, but the therapeutic approach and direction of the group discussion were within my discretion.
Before going further, I think that it’s important to outline a few of the patient populations the hospital served. My home unit, which was known as the Adult “high-functioning” unit, consisted of adult patients from the ages of 18 years of age to mid-50s, living with depression, anxiety, OCD, mood disorders or as of recent, certain personality disorders. Other units where I worked were child and adolescent units, which treated children from the ages of 13-17, a Geriatric unit that worked with patients usually older than 60, with patients sometimes presenting with neurocognitive disorders like Alzheimer’s or Dementia, as well as other psychological disorders like depression or anxiety. There was one main Substance Abuse Adult unit that dealt with both drug and alcohol abuse and patients with comorbid psychological diagnoses. Finally, there were two acute units that housed patients with more severe mental illness, like schizophrenia and psychosis.
Despite these ranges of patient populations, and oftentimes varying patient demographics and identities within each unit, psychiatric techs routinely led groups (except on the more severe mental health unit). Automatically, this presents an issue for patient improvement as successful and efficient groups often screen patients for level of functioning to ensure that people with the same diagnoses have the ability to participate in group. As a psychiatric tech, within the hospital, we could not do this. Another issue that arises from varying function levels, diagnoses, and diverse, layered, patient identities is that you have people with the same diagnoses suffering with more severe symptoms, the possibility of new medications interfering with the ability to remain present in the group, and certain systems and structures of oppression and privilege at play, resulting in microaggressions made by group members or group leaders, that may cause harm, ruptures or fear.
Oftentimes, I saw how these consequences from lack of training, preparation, and screening, both with my own experience as a group leader and an observer of other tech-led groups, resulted in an unsafe space for certain group members. When I brought up this issue of lack of training to lead group sessions with little direction and no supervision to my supervisors, I was met with answers like “that’s just how it is” or “watch how other techs lead groups and learn from them.”
Solutions such as these are rooted in error because specialized training and education is essential for group leaders so that we develop expertise (Barlow, 2018). Simply “learning from other techs and their methods of leading group” is not sufficient because in my experience, those techs also lacked formal training on group leadership. This idea that group therapy skills can simply be observed and then implemented without training or education perpetuates the idea that group therapy is less effective than individual therapy, where the latter does require formal education at multiple levels, training and practice with supervision, and licensure. Also, meta-analytic studies have shown that group therapy is just as effective as individual therapy (Barlow, 2018) and if that’s the case, should be treated within the same regard and realm of specialty.
While leading groups without training or supervision, I found myself constantly worrying about whether or not I was creating an unsafe space, and struggled with navigating difficult topics and feelings my patients were experiencing, like suicidality and topics that implicated social issues affecting identity. Many times, ruptures were created, which although is an inevitable process of any therapy, without training, I usually did not know how to repair them.
Something that makes group dynamics so distinct is the idea that a member is both the “receiver of help” and “giver of help”; that the group setting is both interpersonal and intrapersonal (Barlow, 2018). Group therapy falls into this category because many times, I would see patients try the role of “therapist” by offering advice or going a step further to attempt to empathize with their prospective members by sharing a similar experience or struggle and how they managed/intervened with it. Despite good intentions, this exercise would sometimes be off-putting or land on someone in an opposite manner than intended, causing a rupture within the group dynamic. Because group therapy in inpatient hospitals is vastly different from group therapy in a practice or counseling setting, these ruptures, if not repaired, would be carried on outside of the group during other therapeutic activities or structured down-times.
Lastly, staff-shortages and lack of consistency in group leadership due to staff changes, and with group dynamics constantly changing week to week with new admissions and discharges, training becomes that much more necessary to deal with the associated effects of these uncontrollable situations that arise in hospital settings. Since techs had control over what was talked about, who could attend group (usually not based on actual screening measures), and how the group would be run, I saw how the lack of congruent approaches and leadership negatively impacted patient treatment, usually resulting in valid concerns of group safety, progress and in many cases, avoidance of treatment.
I understand that on a structural level, mental health hospitals deal with many barriers or aspects of health care that can affect standard group preparation, screening, supervision and leadership. Despite this, I do think that if hospitals are going to utilize group therapy as its main form of therapy, staff who are tasked with leading groups should be required to complete some form of training from trained professionals with expertise, and should prioritize supervision and co-leadership, to help mitigate and repair for ruptures or other issues that may arise. At the hospital I worked at, some of the social work groups were led by social work trainees and were supervised by licensed social workers. This policy should be extended to techs, especially because unlike social-work trainees, not all techs possess a background in psychology or a psychology-related field. Furthermore, a screening process should take place during intake to assess which type of group a patient might be better suited for. This solution proposes multiple groups to be run on a unit, which is possible, considering techs and nurses work in 12-hour shifts, and at the hospital I worked at, only about 4-5 hours were dedicated to meetings with the psychiatrists, social workers or expressive therapists, and the rest of the shift was appointed for meals and “down-time.” Again, for this solution to be successful, more training would be necessary to lead specialized, diagnosis specific groups.
Patient treatment and care should be the number one priority, and as a former tech and current graduate student taking a Group Psychotherapy course, it’s important that all techs and staff tasked with leading a group should be offered some type of training or education in order to do less harm and promote patient improvement.
Reference
Barlow, S. H. (2008). Group psychotherapy specialty practice. Professional Psychology: Research and Practice, 39(2), 240–244. https://doi.org/10.1037/0735-7028.39.2.240
A parallel process: the silencing of racism in the work place, group and supervision
Yewon Kim, M.Psy.
George Washington School of Professional Psychology
Abstract
This paper analyzes the group dynamics of a womens’ trauma group in a training program where there are three participants, two leaders (one licensed white clinician and one graduate student of color) and two observers (both graduate students of color). In particular, it explores how the power dynamics of having a sole white licensed clinician and three graduate students of color disagree on the possible racism a group member is describing at her work place. It shows how the group member who is experiencing racism is also the sole black individual in the group, and she struggles to name racism as a contributing factor until it is named by a student leader of color. It concludes by reflecings on how a silent group observer can change the course of a group and challenge the silencing of racism but is faced with consequences for challenging white heteronormativity.
In January 2022, I was invited by a professor, Dr. A to be the second observer of a womens’ trauma group. Dr. A was a cis-white woman who had more power than the average professor within the school and the clinic due to her seniority and her role as a clinical co-director of the Clinic. Despite the clinic’s efforts to be discrete, it was very clear to everyone in the clinic that the students Dr. A favored were given the more coveted and reputable clinical assignments and supervisors. I am a cis-female graduate student who is Asian and of immigrant status in the U.S. At this time, I was a second year student at the school, and I was desperate for additional opportunities. Consequently, I accepted the opportunity without much hesitation as I knew that there were limited spots to observe a group. Group observers were often chosen to be group leaders at the training clinic, and I hoped that volunteering my time would be rewarded by getting the position of being a group leader in the future.
As I was taking on this new role, the group also transitioned online because of COVID-19. The group consisted of three members, Ms. X, Ms. Y and Ms. Z, two leaders and two observers, one of them being me. All the participants were also in individual therapy. Ms. Y and Ms. Z were cis White women and Ms. X was a cis Black woman. There were two leaders in the group Dr. A and another grad student Ms. B. Ms. B was an Asian graduate student much like me but was one year senior. The other observers was Ms. C, and she was half latina and half white..
When I joined to observe the group, Ms. C had already been observing for the few months that Ms. B and Dr. A had been leading the group. I was introduced as a second observer briefly at the beginning of a session, and for the rest of the sessions, I and the other observer had our cameras and audio off. As observers, were just black boxes on everyone’s screens. About two months into observing group, after I had understood the group dynamics, Ms. X brought up a struggle she experienced at work. She worked as a waitress at a restaurant where the rest of the servers were predominantly white. She described that she was being called out for not being fast enough even though she worked longer hours and was given less tables than the rest of the staff. She shared how her coworkers who were on their phones at work didn’t get the same feedback as she did even though she was always attentive at the job. During the group session, the other members of the group were supportive and tried their best to ask questions to explore her struggles deeper but didn’t seem to get any conclusive answers as to her unfair experience at work.
During the supervision with the leaders after the session, I brought up the possibility that racism was a contributing factor to her being singled out for being slow at work. I shared how being slow has been a common stereotype for Black people. Dr. A responded to this comment by stating that she knew Ms. X better as she had worked with her longer. She hypothesized that Ms. X had been the cause of her conflict at work as she had run into similar problems at her previous workplaces that had more people of color. In essence, Dr. A appeared to dismiss my suggestion that racism was contributing to Ms. X’s experiences at work. In response to that, I noted that racism could still be a contributor regardless of this history as people of color can internalize racism and project that onto Ms. X who was darker skinned and had a visible facial scarring. Dr. A acknowledged my comment, but I felt dismissed when she stated that she wanted to use this opportunity to address Ms. X’s intrapsychic tendency to victimize herself. This comment infuriated me because it reminded me of how racism systemicslly works to place the blame on people of color but I recognized the power imbalance between us so I decided to refrain from pushing this further.
In the following session, it appeared that Ms. X’s difficulty at work got worse. Ms. X described how she was now asked to do extra shifts at the last minute and was not given the tables that had higher tip potential. She described how despite the fact that she was working more hours than everyone else, she was still being singled out for not pulling the weight for the rest of the staff. As the other group members attempted to explore her problem again, I noticed how the group was exploring every possibility except for racism. I felt infuriated because it reminded me of all the times in my life when white people were blind to the power of racism. As a woman of color, it was very clear that racism was a big contributing factor to her experience of exclusion and scapegoating at work. In the heat of the moment, I messaged my fellow observer, Ms. C to reality test my thoughts, and she agreed. This peer acceptance was what gave me the courage to push this further despite Dr. A’s rejection of my hypothesis in the previous supervision session. As Ms. X continued to answer various questions posed by the two white participants and Dr. A about the possibility of her role in the discrimination she was experiencing at work, she appeared more and more apologetic. She seemed shameful of herself as she tried to answer questions such as, “what do you think you did to make them have negative judgements about you?”. The more I listened, the more I felt infuriated. My anger towards the reenactment of racism towards Ms. X exceeded the fear I had for the possible consequences of disobeying my role as an observer.
After much hesitation, I decided to reach out to Ms. B, the group leader who was an Asian graduate student and the only person who could intervene in the group aside from Dr. A. Through private chat, I pleaded Ms. B to bring up the possibility of racism to Ms. X. Ms. B understood without further explanation, she agreed, waited for the right time to ask Ms. X, “Do you think racism is playing a role here?”. Ms. X’s face lit up at that moment and proclaimed, “Yes, definitely!” and she continued to share how many of her coworkers were white and scapegoating her to make her work harder and receive less credit. At this moment, the white participants’ and Dr. A’s demeanor changed. They came to a moment of realization that confirmed that “those in the majority tend to be unaware of their privilege” (Debiak, 2007). The group members started to express their sorrows for her experiences and admitted to not having personal experiences with racism. When racism was acknowledged in the room, the focus of the group’s attention changed. The onus of the responsibility moved from Ms. X to her workers, and the question went from “What can Ms. X do to fix the situation?” to “How can Ms. X protect herself from experiencing further racism?” The nuance in the change may appear slight to some, but the impact was drastic. Ms. X’s emotional experience also transformed during the group. Ms. X appeared visibly more comforted and less self-effacing. She was also able to express more of her frustration and anger explicitly without apologizing or making excuses for herself.
During the supervision after the session, Dr. A thanked Ms. B for bringing up racism and noted the drastic change it made in the group discussion. Ms. B acknowledged my contribution to this question, and this created an awkward dynamic as it reminded Dr. A that I had brought up this intervention in the previous session, which she had rejected. I wonder if it was awkward for Dr. A because she had been corrected for her whiteness by a younger, less experienced, minority graduate student. It was certainly awkward for me because I had found a way to intervene despite being an observer. I was worried about being punished for disobeying the boundaries of my role in the group, but I felt ethically justified in my decision to help this group member and comforted by the support of my fellow POC graduate students. We were powerless as individuals but we had strength in numbers. To my surprise, Dr. A acknowledged that she had been wrong and admitted to being corrected. I wanted to use this opportunity to explore the role of whiteness further but noticed her swiftly shift topic-, perhapes her white fragility kicking in.
In hindsight, there was a parallel process in the group. As Ms. X tried to cater to her fellow white participants’ worldview and appear receptive to their attempt at empathy, the leaders and observers were also trying to compromise their differing worldviews. Both groups, the supervision group and the therapy group, were being absorbed by the dominant force- whiteness. This is a prime example of how a group is a microcosm of the society (Yalom & Leszcz, 2020) and how groups can “easily replicate oppressive conditions in the larger society” (Hays, 2001). Hence, racial-cultural identities must never be overlooked when understanding the interactions among members in psychotherapy groups. This example shows that even in a group that has one minority group leader, and two minority observers, having one white licensed psychologist with more power still made whiteness the dominating force. Despite there being three minorities and one white person that were running the group, the supervisory power the white person held trumped the number of minorities that were in the group. The sole licensed psychologist in this group, Dr. A held the most power within the group and among the students and had exercised her whiteness in ways that silenced all the minorities intertwined in the group. This silencing of racism can be loud to minorities who have the experiential knowledge to empathize with the denial of racism but remain unnoticed by people who hold whiteness within the larger society. The good news is that through having the courage to speak up, even when not holding the privilege of being a leader, one can make a difference. Even though there was the denial of white privilege and racism in the beginning of the group, the women of color were able to speak up and change the outcome of the group. This is an important lesson on changing systemic oppression and how it is possible, even when only being a small black box on a screen, to make rippling changes in group members’ lives and address racism in groups.
These dynamics also play and mirror the macrolevel dynamics of group processes. As Layton (2019) and Comes-Diaz (2016), highlight, there are ways that the normative unconscious reorgnizes towards coloniality logics. Unfortunately my attemtp to correct whiteness came at a cost, in which I was not provided an opportunity to lead group despite the months of free labor I provided as an observer. As a woman of color in academia, I was unsurprised to find out that the disobeyal of Dr. A resulted in a chain of silent consequences behind the overt performance of political correctness. The power of whiteness lies in silently correcting those who challenges whiteness (Oluo, 2018): just as Ms. X was “corrected” at her workplace, I was too being “corrected” at my school.
Citations
Comas-Díaz, L. (2016). Racial trauma recovery: A race-informed therapeutic approach to racial wounds. The Cost of Racism for People of Color: Contextualizing Experiences of Discrimination., 249–272. https://doi.org/10.1037/14852-012
Debiak, D. (2007). Attending to diversity in group psychotherapy: An ethical imperative. International Journal of Group Psychotherapy, 57(1), 1–12. https://doi.org/10.1521/ijgp.2007.57.1.1
Hays, P. A. (2001). Addressing cultural complexities in practice: A framework for clinicians and counselors., 170. https://doi.org/10.1037/10411-000
Lynne Layton (2019) Transgenerational Hauntings: Toward a Social Psychoanalysis and an Ethic of Dis-Illusionment, Psychoanalytic Dialogues, 29:2, 105-121, DOI: 10.1080/10481885.2019.1587992
Oluo, I. (2018). So you want to talk about race. Seal Press.
Ribeiro, M. D. (2020). Intersectionality, social identities, and groups examined. Examining Social Identities and Diversity Issues in Group Therapy, 3–24. https://doi.org/10.4324/9780429022364-1
Yalom, I. D., & Leszcz, M. (2020). The Theory and Practice of Group Psychotherapy (5th ed.). Basic Books.
Fall 2022 Pre-Doc Forum
Student Research Review & Articles
Research Review
Group Member’s sense of safety and visibility in group therapy
Yifei Du, MS, MExpArtsTherapy
George Washington School of Professional Psychology
Two research studies’ findings resonate with me deeply, given my own experience as an international graduate student living and studying in the United States for the first time. While it may seem that cultural concealment and feedback are two unrelated concepts, they both connect to a member’s sense of safety and visibility in a group. For example, a minority group member who conceals their cultural identity may receive less positive and negative feedback in group (which results in worse improvement), and they are likely to feel unseen. On the other hand, a minority group member may receive less positive feedback and more negative feedback (also leading to less improvement), and they are likely to feel unsafe and attacked in the group based on their identity. In both situations, the minority member may be more prone to hide their cultural self and experience to protect themselves from a negative group experience, which further stimulates an undesirable amount or negative feedback from the group (and less perceived improvement and positive group process). Thus, a vicious loop develops. The two research articles I will describe will support the need for effective strategies for group leaders to incorporate into their practice. By writing this review, I hope that more group leaders and educators will become aware of needs of diverse patients.
- Rigg, T., & Kivlighan, D. M. (2022). Examining between-group and within-group cultural concealment in group therapy. Professional Psychology: Research and Practice, 53(3), 244-252. DOI: https://doi.org/10.1037/pro0000458
With growing awareness and emphasis on multicultural encounters in the psychotherapy space, there has been a surge in the publication of multicultural theories and studies for both individual therapy and group therapy. Nevertheless, few studies investigated the phenomenon and effect of cultural concealment, i.e., clients’ avoidance or non-disclosure of their cultural selves and experiences in therapy (Drinane, et. al., 2018). In their research, Rigg and Kivlighan (2022) sought to explore the correlation between an individual member’s cultural concealment and the group’s cultural concealment norm on members’ perceptions of improvement, group cohesion, and a global therapeutic factor.
Summary of Research & Findings
The study collected data from 341 clients from 81 process groups at 14 university counseling centers. The Cultural Concealment Questionnaire, Patient Estimate of Improvement, Therapeutic Factor Inventory, and Group Entitativity Measure were utilized to measure participants’ cultural concealment degree, the estimate of the improvement in group therapy, perception of a global group therapeutic factor, and perception of group cohesion. Hierarchical linear modeling and sensitivity analyses were conducted for data analysis. The study findings showed that a group member’s cultural concealment in the group is negatively associated with their perceptions of improvement, group cohesion, and group processes. Furthermore, the group concealment norm was negatively associated with members’ perceptions of the group process, but not associated with members’ estimated improvement or group cohesion. However, no significant difference between group- and individual-level ratings of cultural concealment on clients’ perceptions of improvement and group process is observed. In addition to the original hypotheses, the statistical results also indicated that there are other factors, beyond cultural concealment, influence clients’ perceptions of improvement, group cohesion, and a global therapeutic factor.
Summary of Study Implications
The study indicated significant correlations between a group member’s cultural concealment and their perceived improvement, group cohesion, and group process. Therefore, it is important for group leaders to pay attention to potential cultural concealment among group members and to foster an inclusive group environment with space for members to explore their cultural selves and experiences. Several actions could be taken to achieve this group. First of all, it would be beneficial for group leaders to foster positive cultural norms early in the life of the group. Specifically, during the prescreening and preparation meetings, group leaders could talk about potential sharing of culture and respond to group members feelings and concerns. It is also recommended that group leaders set examples for their cultural humility and cultural comfort in the group. Moreover, when negative cultural processes are detected in the group, group leaders can interrupt, name what is happening, and protect group members from microaggressions. In addition, since cultural concealment could be easily missed in groups, group leaders may want to utilize questionnaires, such as Cultural Concealment Questionnaire, to gather data and identify these processes as they occur in group therapy. By using such measures and inviting members to revisit such conversation in the group process, members may perceive more cultural opportunities in the group.
Comments
It is interesting to note that only the first hypothesis – a group member’s individual cultural concealment would be negatively associated with their perceptions of improvement and group processes – is supported. Indeed, cultural concealment could be a highly private thing that neither group leaders nor other group members are aware of. For instance, in a group where the majority of the members identified as heterosexual, a group member who identified with homosexual orientation could feel terribly isolated and uneasy to express their cultural self and experience in the group. Others in the group, however, might not be aware of the circumstance and might even feel that the group is LGBTQ friendly. Therefore, group-level cultural concealment may not necessarily reflect each group member’s feelings or their estimate of improvement or perception of the group processes. Neither was a contextual effect supported. Only a client, themselves, know their cultural concealment the best, and group leaders should respect and validate their feelings, non-defensively, as the bottom line.
- Kivlighan, D. M., Ali, R. W., & Garrison, Y. L. (2020). Is there an optimal level of positive and negative feedback in group therapy? A response surface analysis. Psychotherapy, 57(2), 174–183. DOI: https://doi.org/10.1037/pst0000244
Feedback is considered an essential therapeutic intervention in various theoretical frameworks. In group therapy, feedback is a key tool to facilitate interpersonal learning, particularly in groups that focus on interpersonal processes. There are, however, few studies exploring examining the ideal amount of feedback, specifically positive and negative feedback, for client outcomes or personal growth. In their research, Kivlighan and his colleagues (2020) explored whether perceived congruent and high levels of positive and negative feedback among group members correlate with group members’ perception of group cohesion.
Summary of Procedure & Findings
The study recruited 168 participants from 10 university counseling centers that offered interpersonal process therapy groups. Participants perceived amount of feedback, group cohesion, and improvement were gathered by a two-item questionnaire, the Group Entitativity Measure (GEM) for group cohesiveness, and the Patient’s Estimate of Improvement, respectively. Polynomial regression and response surface analysis were conducted for data analysis. The results showed that participants perceived greater amounts of positive feedback compared with negative feedback, at 4.03 and 2.78 out of 5 respectively. Moreover, the average rating of cohesion and improvement among participants were at moderate levels. Among the four independent variables, significant between-group variances were observed for members’ perceptions of positive feedback, group cohesion, and improvement. Members’ perceptions of positive feedback were significantly related to members’ perceptions of group cohesion and improvement. Additionally, members perceived high group cohesion when their perceptions of positive and negative feedback are congruent and high. Nevertheless, when members perceived high positive feedback and low negative feedback, the perceived group cohesion is the highest. On the other hand, estimated improvement is at its highest when the perceived positive and negative feedback are congruent and high. The estimated improvement is also high when perceived positive feedback is high and negative feedback is low. However, estimated improvements are lowest when members’ perceptions of positive and negative feedback are congruent and low, or perceived positive feedback is low while negative feedback is high.
Summary of Clinical Implications
The research provided several clinical implications for group leaders. First and foremost, group leaders are recommended to work to create a group environment where group members can share both positive and negative feedback. For the best possible group cohesion and improvement, positive-negative and positive-negative-positive amount of feedback are advised. Group leaders may consider group preparation, including discussion on the role and benefit of both positive and negative feedback, model giving and receiving feedback, and establish norms regarding giving and receiving feedback early in the life of the group to help foster a feedback-encouraged environment. In addition, it would be beneficial to explore potential obstacles when little feedback is provided among the members.
Limitations of Research
This research provided a preliminary indication of the significance of having balanced and high amounts of positive and negative feedback or discrepant high positive feedback and low negative feedback in interpersonal process group therapy. So far as I am concerned, there are three things that need further consider. Firstly, the accuracy of participants’ perceptions could be influenced by individual biases since all of the data are self-reported perceptions. A group member who feels awkward receiving positive feedback, for instance, might perceive that more positive feedback was offered by other group members than actually occurred. As a result, there could be a discrepancy between the ideal level of feedback amount the group leaders intended to encourage, and the level of feedback group members actually felt they received. Secondly, as the paper noted, Stockton and Morran (1980) identified seven factors influencing the feedback process, namely sequence, sender characteristics, focus, timing, amount, receiver characteristics, and group atmosphere. The correlation between feedback and group cohesion and outcome could be impacted and complicated by each group factors listed above. Further investigation that takes these factors into account would therefore offer the matter more sophistication. Last but not least, group composition and group heterogeneity – including differences in age, culture, functioning level of group members, etc. – can also have an impact on the outcomes. In this study, participants are all undergraduate and graduate students who may present at a relatively high level of functioning. Would the same results be replicated in groups with more heterogeneity and/or consisting of members with lower functioning levels? It is hard to say. Therefore, a close look at group composition and group heterogeneity would also add more perspectives for clinical ramifications.
Brief Article 1
Running Group Therapy Without Training: My Experience As A Group Leader While Working As A Psychiatric Technician
By Cara Judkins, BS
George Washington School of Professional Psychology
Abstract
In 2018, the American Psychological Association (APA) recognized Group Psychotherapy and Group Psychology as specialties, which require specialized education and training. The definition of group therapy has expanded over time to include various models of therapeutic approaches. However, a comprehensive definition includes any group dynamic that is used for prevention, training, counseling or guidance (Barlow, 2018). Regardless of the setting, leading a therapy group involves experience in working with certain populations, repairing ruptures, assessing for microaggressions, and understanding that the group is a microcosm of the real world. The purpose of this brief report is to reflect on my experience working as a Psychiatric Technician with the responsibility of leading therapeutic groups on inpatient units without specialized education or training, and the implications that can have on patients and the group as a whole.
Before starting graduate school for my Doctorate in Clinical Psychology (Psy.D.), I worked as a Psychiatric Technician at a local inpatient mental health hospital where I gained experience working with adults, adolescents and elderly populations, all presenting with a diverse range of diagnoses. Despite this wide variety of presenting problems, personality styles, disorders and levels of organization, one job duty remained the same across house: leading group therapy sessions. Whether working as a technician on the day shift or night shift, the responsibility was the same—facilitating either an AM or PM group session. These sessions were shorter than the standard psychotherapy group session, usually lasting a maximum of one hour rather than the standard hour and a half psychotherapy group.
As Psychiatric Technicians, it was our job to provide a specific protocol for each patient attending the group session:
- Mood rating sheet- prompting the patient to (1) rate mood from 1-10 with 1 being the lowest and 10 the highest;
- list any personal goals for the day;
- list aspects of healing or personal growth the patient wished to improve on;
- list any resources the staff or hospital might provide for those goals; and
- list any comments, concerns or questions that needed to be addressed.
During onboarding, supervisors advised me that this sheet was a type of outline to follow that should help guide the patients, but the therapeutic approach and direction of the group discussion were within my discretion.
Before going further, I think that it’s important to outline a few of the patient populations the hospital served. My home unit, which was known as the Adult “high-functioning” unit, consisted of adult patients from the ages of 18 years of age to mid-50s, living with depression, anxiety, OCD, mood disorders or as of recent, certain personality disorders. Other units where I worked were child and adolescent units, which treated children from the ages of 13-17, a Geriatric unit that worked with patients usually older than 60, with patients sometimes presenting with neurocognitive disorders like Alzheimer’s or Dementia, as well as other psychological disorders like depression or anxiety. There was one main Substance Abuse Adult unit that dealt with both drug and alcohol abuse and patients with comorbid psychological diagnoses. Finally, there were two acute units that housed patients with more severe mental illness, like schizophrenia and psychosis.
Despite these ranges of patient populations, and oftentimes varying patient demographics and identities within each unit, psychiatric techs routinely led groups (except on the more severe mental health unit). Automatically, this presents an issue for patient improvement as successful and efficient groups often screen patients for level of functioning to ensure that people with the same diagnoses have the ability to participate in group. As a psychiatric tech, within the hospital, we could not do this. Another issue that arises from varying function levels, diagnoses, and diverse, layered, patient identities is that you have people with the same diagnoses suffering with more severe symptoms, the possibility of new medications interfering with the ability to remain present in the group, and certain systems and structures of oppression and privilege at play, resulting in microaggressions made by group members or group leaders, that may cause harm, ruptures or fear.
Oftentimes, I saw how these consequences from lack of training, preparation, and screening, both with my own experience as a group leader and an observer of other tech-led groups, resulted in an unsafe space for certain group members. When I brought up this issue of lack of training to lead group sessions with little direction and no supervision to my supervisors, I was met with answers like “that’s just how it is” or “watch how other techs lead groups and learn from them.”
Solutions such as these are rooted in error because specialized training and education is essential for group leaders so that we develop expertise (Barlow, 2018). Simply “learning from other techs and their methods of leading group” is not sufficient because in my experience, those techs also lacked formal training on group leadership. This idea that group therapy skills can simply be observed and then implemented without training or education perpetuates the idea that group therapy is less effective than individual therapy, where the latter does require formal education at multiple levels, training and practice with supervision, and licensure. Also, meta-analytic studies have shown that group therapy is just as effective as individual therapy (Barlow, 2018) and if that’s the case, should be treated within the same regard and realm of specialty.
While leading groups without training or supervision, I found myself constantly worrying about whether or not I was creating an unsafe space, and struggled with navigating difficult topics and feelings my patients were experiencing, like suicidality and topics that implicated social issues affecting identity. Many times, ruptures were created, which although is an inevitable process of any therapy, without training, I usually did not know how to repair them.
Something that makes group dynamics so distinct is the idea that a member is both the “receiver of help” and “giver of help”; that the group setting is both interpersonal and intrapersonal (Barlow, 2018). Group therapy falls into this category because many times, I would see patients try the role of “therapist” by offering advice or going a step further to attempt to empathize with their prospective members by sharing a similar experience or struggle and how they managed/intervened with it. Despite good intentions, this exercise would sometimes be off-putting or land on someone in an opposite manner than intended, causing a rupture within the group dynamic. Because group therapy in inpatient hospitals is vastly different from group therapy in a practice or counseling setting, these ruptures, if not repaired, would be carried on outside of the group during other therapeutic activities or structured down-times.
Lastly, staff-shortages and lack of consistency in group leadership due to staff changes, and with group dynamics constantly changing week to week with new admissions and discharges, training becomes that much more necessary to deal with the associated effects of these uncontrollable situations that arise in hospital settings. Since techs had control over what was talked about, who could attend group (usually not based on actual screening measures), and how the group would be run, I saw how the lack of congruent approaches and leadership negatively impacted patient treatment, usually resulting in valid concerns of group safety, progress and in many cases, avoidance of treatment.
I understand that on a structural level, mental health hospitals deal with many barriers or aspects of health care that can affect standard group preparation, screening, supervision and leadership. Despite this, I do think that if hospitals are going to utilize group therapy as its main form of therapy, staff who are tasked with leading groups should be required to complete some form of training from trained professionals with expertise, and should prioritize supervision and co-leadership, to help mitigate and repair for ruptures or other issues that may arise. At the hospital I worked at, some of the social work groups were led by social work trainees and were supervised by licensed social workers. This policy should be extended to techs, especially because unlike social-work trainees, not all techs possess a background in psychology or a psychology-related field. Furthermore, a screening process should take place during intake to assess which type of group a patient might be better suited for. This solution proposes multiple groups to be run on a unit, which is possible, considering techs and nurses work in 12-hour shifts, and at the hospital I worked at, only about 4-5 hours were dedicated to meetings with the psychiatrists, social workers or expressive therapists, and the rest of the shift was appointed for meals and “down-time.” Again, for this solution to be successful, more training would be necessary to lead specialized, diagnosis specific groups.
Patient treatment and care should be the number one priority, and as a former tech and current graduate student taking a Group Psychotherapy course, it’s important that all techs and staff tasked with leading a group should be offered some type of training or education in order to do less harm and promote patient improvement.
Reference
Barlow, S. H. (2008). Group psychotherapy specialty practice. Professional Psychology: Research and Practice, 39(2), 240–244. https://doi.org/10.1037/0735-7028.39.2.240
Brief Article 2
A parallel process: the silencing of racism in the work place, group and supervision
Yewon Kim, M.Psy.
George Washington School of Professional Psychology
Abstract
This paper analyzes the group dynamics of a womens’ trauma group in a training program where there are three participants, two leaders (one licensed white clinician and one graduate student of color) and two observers (both graduate students of color). In particular, it explores how the power dynamics of having a sole white licensed clinician and three graduate students of color disagree on the possible racism a group member is describing at her work place. It shows how the group member who is experiencing racism is also the sole black individual in the group, and she struggles to name racism as a contributing factor until it is named by a student leader of color. It concludes by reflecings on how a silent group observer can change the course of a group and challenge the silencing of racism but is faced with consequences for challenging white heteronormativity.
In January 2022, I was invited by a professor, Dr. A to be the second observer of a womens’ trauma group. Dr. A was a cis-white woman who had more power than the average professor within the school and the clinic due to her seniority and her role as a clinical co-director of the Clinic. Despite the clinic’s efforts to be discrete, it was very clear to everyone in the clinic that the students Dr. A favored were given the more coveted and reputable clinical assignments and supervisors. I am a cis-female graduate student who is Asian and of immigrant status in the U.S. At this time, I was a second year student at the school, and I was desperate for additional opportunities. Consequently, I accepted the opportunity without much hesitation as I knew that there were limited spots to observe a group. Group observers were often chosen to be group leaders at the training clinic, and I hoped that volunteering my time would be rewarded by getting the position of being a group leader in the future.
As I was taking on this new role, the group also transitioned online because of COVID-19. The group consisted of three members, Ms. X, Ms. Y and Ms. Z, two leaders and two observers, one of them being me. All the participants were also in individual therapy. Ms. Y and Ms. Z were cis White women and Ms. X was a cis Black woman. There were two leaders in the group Dr. A and another grad student Ms. B. Ms. B was an Asian graduate student much like me but was one year senior. The other observers was Ms. C, and she was half latina and half white..
When I joined to observe the group, Ms. C had already been observing for the few months that Ms. B and Dr. A had been leading the group. I was introduced as a second observer briefly at the beginning of a session, and for the rest of the sessions, I and the other observer had our cameras and audio off. As observers, were just black boxes on everyone’s screens. About two months into observing group, after I had understood the group dynamics, Ms. X brought up a struggle she experienced at work. She worked as a waitress at a restaurant where the rest of the servers were predominantly white. She described that she was being called out for not being fast enough even though she worked longer hours and was given less tables than the rest of the staff. She shared how her coworkers who were on their phones at work didn’t get the same feedback as she did even though she was always attentive at the job. During the group session, the other members of the group were supportive and tried their best to ask questions to explore her struggles deeper but didn’t seem to get any conclusive answers as to her unfair experience at work.
During the supervision with the leaders after the session, I brought up the possibility that racism was a contributing factor to her being singled out for being slow at work. I shared how being slow has been a common stereotype for Black people. Dr. A responded to this comment by stating that she knew Ms. X better as she had worked with her longer. She hypothesized that Ms. X had been the cause of her conflict at work as she had run into similar problems at her previous workplaces that had more people of color. In essence, Dr. A appeared to dismiss my suggestion that racism was contributing to Ms. X’s experiences at work. In response to that, I noted that racism could still be a contributor regardless of this history as people of color can internalize racism and project that onto Ms. X who was darker skinned and had a visible facial scarring. Dr. A acknowledged my comment, but I felt dismissed when she stated that she wanted to use this opportunity to address Ms. X’s intrapsychic tendency to victimize herself. This comment infuriated me because it reminded me of how racism systemicslly works to place the blame on people of color but I recognized the power imbalance between us so I decided to refrain from pushing this further.
In the following session, it appeared that Ms. X’s difficulty at work got worse. Ms. X described how she was now asked to do extra shifts at the last minute and was not given the tables that had higher tip potential. She described how despite the fact that she was working more hours than everyone else, she was still being singled out for not pulling the weight for the rest of the staff. As the other group members attempted to explore her problem again, I noticed how the group was exploring every possibility except for racism. I felt infuriated because it reminded me of all the times in my life when white people were blind to the power of racism. As a woman of color, it was very clear that racism was a big contributing factor to her experience of exclusion and scapegoating at work. In the heat of the moment, I messaged my fellow observer, Ms. C to reality test my thoughts, and she agreed. This peer acceptance was what gave me the courage to push this further despite Dr. A’s rejection of my hypothesis in the previous supervision session. As Ms. X continued to answer various questions posed by the two white participants and Dr. A about the possibility of her role in the discrimination she was experiencing at work, she appeared more and more apologetic. She seemed shameful of herself as she tried to answer questions such as, “what do you think you did to make them have negative judgements about you?”. The more I listened, the more I felt infuriated. My anger towards the reenactment of racism towards Ms. X exceeded the fear I had for the possible consequences of disobeying my role as an observer.
After much hesitation, I decided to reach out to Ms. B, the group leader who was an Asian graduate student and the only person who could intervene in the group aside from Dr. A. Through private chat, I pleaded Ms. B to bring up the possibility of racism to Ms. X. Ms. B understood without further explanation, she agreed, waited for the right time to ask Ms. X, “Do you think racism is playing a role here?”. Ms. X’s face lit up at that moment and proclaimed, “Yes, definitely!” and she continued to share how many of her coworkers were white and scapegoating her to make her work harder and receive less credit. At this moment, the white participants’ and Dr. A’s demeanor changed. They came to a moment of realization that confirmed that “those in the majority tend to be unaware of their privilege” (Debiak, 2007). The group members started to express their sorrows for her experiences and admitted to not having personal experiences with racism. When racism was acknowledged in the room, the focus of the group’s attention changed. The onus of the responsibility moved from Ms. X to her workers, and the question went from “What can Ms. X do to fix the situation?” to “How can Ms. X protect herself from experiencing further racism?” The nuance in the change may appear slight to some, but the impact was drastic. Ms. X’s emotional experience also transformed during the group. Ms. X appeared visibly more comforted and less self-effacing. She was also able to express more of her frustration and anger explicitly without apologizing or making excuses for herself.
During the supervision after the session, Dr. A thanked Ms. B for bringing up racism and noted the drastic change it made in the group discussion. Ms. B acknowledged my contribution to this question, and this created an awkward dynamic as it reminded Dr. A that I had brought up this intervention in the previous session, which she had rejected. I wonder if it was awkward for Dr. A because she had been corrected for her whiteness by a younger, less experienced, minority graduate student. It was certainly awkward for me because I had found a way to intervene despite being an observer. I was worried about being punished for disobeying the boundaries of my role in the group, but I felt ethically justified in my decision to help this group member and comforted by the support of my fellow POC graduate students. We were powerless as individuals but we had strength in numbers. To my surprise, Dr. A acknowledged that she had been wrong and admitted to being corrected. I wanted to use this opportunity to explore the role of whiteness further but noticed her swiftly shift topic-, perhapes her white fragility kicking in.
In hindsight, there was a parallel process in the group. As Ms. X tried to cater to her fellow white participants’ worldview and appear receptive to their attempt at empathy, the leaders and observers were also trying to compromise their differing worldviews. Both groups, the supervision group and the therapy group, were being absorbed by the dominant force- whiteness. This is a prime example of how a group is a microcosm of the society (Yalom & Leszcz, 2020) and how groups can “easily replicate oppressive conditions in the larger society” (Hays, 2001). Hence, racial-cultural identities must never be overlooked when understanding the interactions among members in psychotherapy groups. This example shows that even in a group that has one minority group leader, and two minority observers, having one white licensed psychologist with more power still made whiteness the dominating force. Despite there being three minorities and one white person that were running the group, the supervisory power the white person held trumped the number of minorities that were in the group. The sole licensed psychologist in this group, Dr. A held the most power within the group and among the students and had exercised her whiteness in ways that silenced all the minorities intertwined in the group. This silencing of racism can be loud to minorities who have the experiential knowledge to empathize with the denial of racism but remain unnoticed by people who hold whiteness within the larger society. The good news is that through having the courage to speak up, even when not holding the privilege of being a leader, one can make a difference. Even though there was the denial of white privilege and racism in the beginning of the group, the women of color were able to speak up and change the outcome of the group. This is an important lesson on changing systemic oppression and how it is possible, even when only being a small black box on a screen, to make rippling changes in group members’ lives and address racism in groups.
These dynamics also play and mirror the macrolevel dynamics of group processes. As Layton (2019) and Comes-Diaz (2016), highlight, there are ways that the normative unconscious reorgnizes towards coloniality logics. Unfortunately my attemtp to correct whiteness came at a cost, in which I was not provided an opportunity to lead group despite the months of free labor I provided as an observer. As a woman of color in academia, I was unsurprised to find out that the disobeyal of Dr. A resulted in a chain of silent consequences behind the overt performance of political correctness. The power of whiteness lies in silently correcting those who challenges whiteness (Oluo, 2018): just as Ms. X was “corrected” at her workplace, I was too being “corrected” at my school.
Citations
Comas-Díaz, L. (2016). Racial trauma recovery: A race-informed therapeutic approach to racial wounds. The Cost of Racism for People of Color: Contextualizing Experiences of Discrimination., 249–272. https://doi.org/10.1037/14852-012
Debiak, D. (2007). Attending to diversity in group psychotherapy: An ethical imperative. International Journal of Group Psychotherapy, 57(1), 1–12. https://doi.org/10.1521/ijgp.2007.57.1.1
Hays, P. A. (2001). Addressing cultural complexities in practice: A framework for clinicians and counselors., 170. https://doi.org/10.1037/10411-000
Lynne Layton (2019) Transgenerational Hauntings: Toward a Social Psychoanalysis and an Ethic of Dis-Illusionment, Psychoanalytic Dialogues, 29:2, 105-121, DOI: 10.1080/10481885.2019.1587992
Oluo, I. (2018). So you want to talk about race. Seal Press.
Ribeiro, M. D. (2020). Intersectionality, social identities, and groups examined. Examining Social Identities and Diversity Issues in Group Therapy, 3–24. https://doi.org/10.4324/9780429022364-1
Yalom, I. D., & Leszcz, M. (2020). The Theory and Practice of Group Psychotherapy (5th ed.). Basic Books.