Obstacles, Challenges, and Benefits of Online Group Psychotherapy
Publication: American Journal of Psychotherapy
Abstract
Although telepsychiatry is not new, the COVID-19 pandemic has dramatically boosted and legitimized it, especially in the field of group therapy. Group therapists have been forced to move online without enough training in leading online groups. Online groups are not the same as meeting in person and present specific obstacles and challenges that should either be compensated for or acknowledged as losses. In this article, the author summarizes these obstacles, identifying factors in group therapy, such as body-to-body interaction, that are absent online and suggesting ways to compensate for other differences, such as the therapist’s reduced control over the setting. Surprisingly, some group members may benefit from online groups more than from in-person ones, but the online format is not for everyone. Research on online therapy has already shown this format’s effectiveness, and the therapeutic alliance that is positively correlated with outcome seems to be achievable online as well. However, more research is needed, especially on cohesion in online groups, which seems to develop slower online.
Highlights
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Online therapy groups present specific challenges, which training can help group therapists consider and overcome.
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Some of these obstacles can be overcome and compensated for (e.g., the changed setting), whereas others should be acknowledged as losses (e.g., the absence of body-to-body interactions).
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Factors correlated with positive outcomes, such as the therapeutic alliance, seem to be achievable online, although group cohesion may be slow to develop.
Editor’s Note: This article is part of a special issue on group psychotherapy with Guest Editor Fran Weiss, L.C.S.W.-R., B.C.D. Although authors were invited to submit manuscripts for the themed issue, all articles underwent peer review as per journal policies.
When Fran Weiss, the editor of this special issue on group psychotherapy, approached me in November 2019 and asked if I would write an article about online groups, it would have been difficult to imagine how this topic would become so necessary, urgently needed, and in vogue by March 2020. Group psychotherapy has been considered “the poor cousin” among many individual therapists, and prior to the COVID-19 pandemic, the status of online therapy and especially of online groups was even worse. Therapists leading online groups were looked down on by many colleagues. Many objections were voiced to this new modality. Psychoanalysts I communicated with argued that “this is not psychoanalysis,” and group analysts have claimed, “This is not group analysis” (1). My intention is not to respond to these objections. However, online group therapy can easily meet Foulkes’s (2) definition of group analysis as “the analysis by the group, of the group, including its conductor.”
The COVID-19 pandemic has changed it all. Therapists who never thought they would participate in telemedicine were thrust into it. Within a matter of days or a week, without enough knowledge and preparation, therapists, including group therapists, had to move their sessions with clients and group members online. Something done under compulsion cannot be condemned. Still, there are many caveats against such a quick transition with no training, and, indeed, group therapists have had to face resistance from their clients and their own hesitancies. Group psychotherapists have historically argued that group psychotherapy be considered a specialty requiring specific training. Group psychotherapy was recognized by the American Psychological Association as a specialty in 2018 (see https://www.apadivisions.org/division-49/leadership/committees/group-specialty). If group psychotherapists claim that individual therapy is different from group psychotherapy, the same consideration should apply to moving from the circle to the screen. Although online groups look similar to in-person groups, some important differences should not be ignored. In line with these considerations, this article summarizes the obstacles involved in leading therapy groups online and suggests some ways to deal with them.
Research About Online Groups
Telemedicine is not new, and rural teletherapy (3) has been around for at least 20 years. However, online therapy has come of age during the pandemic. Research about online therapy is accumulating quickly, but online group therapy still has not received enough attention in the research literature, and studies about it remain scarce. Because research on psychotherapy has already established that the therapeutic or working alliance is the most important predictor of positive outcomes in all psychotherapies (4), therapists should first look at whether therapeutic alliance is possible online. Studies confirm that the strongest therapeutic alliance occurs in situations in which the therapist and client agree about the goals and tasks of therapy and that therapeutic alliance is correlated with the quality of the relationship that develops during the therapy (4–6). The first two factors (agreeing on the goals and tasks) can easily be achieved online by discussing the goals and tasks before beginning the group, for example, in the online preparation meeting where the group agreement is discussed. The question about whether the same kind of relationships can be developed online as in person will be addressed in the discussion on presence, below. Simpson and Reid (7), in a review of studies that measured therapeutic alliance in video conference meetings, found that “studies overwhelmingly supported the notion that therapeutic alliance can be developed in psychotherapy over video conference.” The work of Cook and Doyle (8), who compared working alliance between in-person and online therapy, is also instructive.
In groups, cohesion is the best manifestation of the therapeutic relationship (9, 10), which means that in group psychotherapy, the best predictor for positive outcome is group cohesion. Group members who report more relatedness, acceptance, and support also report more symptomatic improvement (11). Group cohesion has also been linked to decreases in premature dropout (10). Unfortunately, research about cohesion in online therapy groups has been rare, except for a few reports (12, 13) concluding that, in online text-based support groups, group cohesion and trust develop from the reassurance that what happens in the group stays in the group. In my experience, group cohesion can develop in online groups, but the development is slower than in in-person groups. The reasons are many: Internet connections are glitchy and vary in clarity among members; only one person can speak at a time (forcing an unnaturally linear group narrative); members are often more resistant to the regressive forces that are active in groups (because regression creates neediness and thus highlights being alone, in pain, in a room with only their computer); members can be inhibited by the presence of family members in the home; transferences around neglect may be intensified; dissociative defenses can be intensified by the nature of an online group; and the small talk before, during, and after the group is eliminated. For a comprehensive review of research on online groups, see Weinberg (14).
Challenges of Online Groups
Some writers (15, 16) have put a lot of effort into ascertaining whether online therapy is similar to or different from in-person therapy. There is no doubt that there are important differences between the two modalities. Just think about the movement from three dimensions to two dimensions. Something is clearly lost. The lost dimension may “flatten” online relationships, making them shallower. In fact, the emphasis for group therapists should be on what is lost and how can we compensate for these losses. Of course, therapists cannot compensate for all losses and challenges (e.g., the lack of body-to-body interactions, as described below), but the benefits of conducting online groups, especially during the pandemic, overrule the disadvantages. Indeed, the online group may become a permanent “exciting object,” as in Fairbairn’s (17) use of this concept, that promises more than can be delivered, but if we do not ignore its pitfalls and obstacles, we may avoid this frustration. Some of the obstacles can be considered grist for the mill (i.e., we can make them useful for working through psychological difficulties), but other factors involved in in-person sessions will remain missing.
Online groups pose several challenges for the therapist. The therapist must know these challenges and consider ways to overcome them. These challenges have been described and discussed in detail in a previous publication (18) and are summarized below.
The Changed Setting
In psychodynamic psychotherapy, the setting is important to create a safe holding environment. Langs (19) wrote an entire book about the setting of the analytic situation (20). Usually, the therapist creates this holding environment by keeping the space and time boundaries and by choosing the furniture and furnishings. Foulkes, the “father of group analysis,” coined the term “dynamic administration” (21), meaning that the group analyst’s administrative functions have dynamic implications. For example, choosing different chairs for the group members conveys the message of different status and privileges. When shifting from the circle to the screen, the therapist no longer controls the setting. The clients (or group members) determine whether the door in their room will be closed, which chair they will sit in, and other environmental conditions. The changed setting is especially important when thinking about the potential for loose boundaries online and the question of confidentiality.
The way to overcome this difficulty is not to assume that the group members know about confidentiality and the correct setting conditions. The group therapist can instruct group members about how to create their own holding environment and prepare them before the group begins. This information can be given during the preparation meeting that is standard practice in group psychotherapy. As mentioned above, the preparation meeting can be conducted online. Setting the frame for online group meetings can also be done through written instructions added to the group agreement, such as, “Please arrange for a quiet room with full privacy and no interruptions. This includes no phone calls, e-mails, or texting during the session.”
Group therapists should not ignore the possibility of Internet failure or other technical disruptions. Because such disruptions are technical, we forget that these disconnections may carry psychological meaning (whom do we blame for the failure?) or may evoke some emotions (e.g., abandonment). Whenever the Internet connection is interrupted (either total disconnection or brief interruption to only the video or audio), the group leader should consider exploring the impact of these interruptions on group members.
The Disembodied Environment
Online group psychotherapy involves a “nonbody” treatment, because the physical bodies of the group members and therapist are perceived only visually and not through other senses, such as smell or somatic sensations. Even the full body is not seen online; participants usually see only the faces of other group members. This limitation becomes clear when trying to use eye contact online (either between coleaders or to make group members feel seen). None of the group members or coleaders know where their gaze is directed. This is a real challenge in applying the interpersonal neurobiological approach, which suggests that we regulate one another’s affects through our body-to-body interactions (usually right brain to right brain) (22, 23). However, our own bodily sensations remain intact during online interactions, but interactions between bodies are lacking. Lemma (15) refers to online therapy as retaining an “embodied presence” because “in cyberspace we are still embodied. What changes is our experience of our own and the other person’s embodiment.”
In the section below, I write about the concept of presence. Most traditional views relate to presence as involving the body. Implicit norms of relationships and communication in Western society presuppose the copresence of two bodies in the intimate and therapeutic interaction. However, the group analytic frame of reference uses the concept of the group matrix as one of the important factors adding to the therapeutic results. This matrix is defined as “the hypothetical web of communication and relationship in a given group” (21) and is not based on the presence of human bodies but instead encompasses the nature of the transpersonal mind and refers to a relational interface.
Group therapists also need to remember that one part of the body, the face, is seen better online than in person, because it is shown in close-up. Online, therapists can better see the facial expressions of group members than when they are present in a room, and if we, as therapists, teach ourselves to read those expressions and to use them well in the group process, we can partially overcome this obstacle. Relating to members’ facial expressions and wondering about their meanings can be perceived as akin to “seeing” group members; however, overusing this technique can be perceived as intrusive. Additionally, the fact that online group members and therapists can see their own faces can be disturbing for some. Because only the upper body is usually seen online, therapists and group members may only dress up from above the waist, which can create embarrassing episodes when they stand.
The Question of Presence
Online group therapists may feel they lose their presence online. Therapeutic presence can be defined as bringing one’s whole self to the engagement with the client and being fully in the moment with and for the client, with little self-centered purpose or goal in mind (24). The group therapist’s presence involves his or her immersion, passion, attention, emotional involvement, reverie, and a readiness to be drawn into enactments (25). Lemma (15) has written that presence is the perception of successfully transforming an intention into action. Geller and Greenberg (26) describe therapeutic presence as the state of having one’s whole self in the encounter with a client or a group by being completely in the moment on multiple levels: physically, emotionally, cognitively, and spiritually.
Although it is more difficult to create this kind of presence online because of various distractions, it remains possible to transform an intention into action. Group therapists can reinforce their presence by increasing their use of self-disclosure and especially by taking responsibility for their mistakes and by acknowledging empathic failures (27). Another way of increasing presence is by asking group members to use their imagination.
For example, in an online group using video conferencing, which moved from in-person to virtual because of the pandemic, one of the group members complained about the boxes showing the group members on the screen and said how much she missed the in-person circle. The group therapist suggested that she imagine the group sitting in a circle and asked her who she imagined sitting beside her and who she imagined sitting across the room from her. This fantasy led to a lengthy discussion in the group about relationships, intimacy, and distance between group members.
Distractions and the Transparent Background
Leading online groups takes more energy and requires more self-discipline than leading in-person groups. It is more difficult to stay focused (both for the group therapist and for the group members) and to avoid being distracted by e-mails, phone messages, or other stimuli in the room. Because of these distractions, group leaders need to be more keenly aware of this difficulty and to take more time and energy to support their group members’ learning.
Strangely enough, group therapists tend to ignore events that happen in their group members’ personal environments as if they did not happen. If someone were to enter the room during an in-person group session, the group members and leader would immediately feel the entrance as a boundary violation and would respond to it. However, when someone passes behind a group member in an online group, typically no one comments on it, including the group leader. Group leaders should be trained not to ignore their group members’ background environments and how to include such events in their interventions without shaming the person involved. When someone enters the room of one of the group members, it is recommended that the therapist gently draw group members’ attention to the interruption. It is usually enough to do this once for group members to remember not to let anyone into the room during a group session.
The therapist should also address the appearance of clients who call in from their beds, appear unshaven or unwashed, or who wear pajamas or inappropriately revealing or sexualized apparel. These issues are difficult enough to deal with in an in-person group. Because they can easily produce narcissistic injury, these issues tend to feel unmentionable online, and an effort should be made to address them.
In the following case vignette, we can see how a violation of the setting is ignored by the group until the group leader addresses it. (A version of this vignette has appeared in a previous publication [28].)
After missing the previous session, Sarah appeared on the screen in the next session sitting in the back seat of a cab and using her cell phone to connect to the group. The group members expressed their thoughts regarding her absence from the previous session, but nobody mentioned that she was in a car with a driver. The group leader inquired whether he was the only one who noticed that Sarah was in a cab on her phone and asked how people felt about it.
Nora said that she was worried about confidentiality and did not feel safe, to which Sarah replied that it was okay, because she did not know the driver. This comment enraged some group members who felt that Sarah was not being considerate of their privacy. Fiona was concerned that Sarah would not be able to emotionally connect with the group. Hella noted that Sarah did not want to miss this group session again and had made the effort to connect, despite being on the road. Sarah was touched by this empathic response and acknowledged that she wanted to get to an important meeting but did not want to miss the group session. She asked the group what to do. Nora wanted Sarah to leave the session and come back next time. David said that Sarah had violated the agreement they all had made when entering the group.
The group leader suggested that Sarah leave the group session and join the next session. Sarah became angry and shouted that the leader and group were inhumane and that she did not want to participate anymore. She disconnected and disappeared from the screen. Some people expressed anger with Sarah and with the group leader. Others were afraid that they would also be rejected if they deviated from group norms. The group leader encouraged expression of all feelings, saying that safety is about the freedom to discuss difficult issues in addition to setting boundaries.
The next meeting Sarah showed up at home, to the everyone’s relief. The group leader suggested discussing the dramatic events from the prior meeting. Sarah thanked everyone for the previous meeting; she had thought a lot about what had happened and about her strong emotional reaction. She said she remembered being rejected by her family and by peers. Other members who had felt rejected through their lives empathized with her and shared their rejection memories. These two meetings became a turning point for the group and increased the members’ ability to express differences and to feel safe in opening up.
Group Members Who Benefit From Online Groups
The sudden shift from in-person to online group therapy caused by COVID-19 in March 2020 created a rare opportunity for an unplanned, spontaneous study comparing group therapy before and after the change. Although I had led in-person and online groups for years, they were separate entities. I could never compare the same group members in continuous in-person and online groups. To my surprise, I found that some group members seemed to function better in online groups than they had in person. These were group members who had specific difficulties in close relationships. The intimacy that develops in groups that meet in person scares and intimidates them so much that they withdraw and have only limited emotional involvement in the group.
Marmarosh et al. (29) wrote that dismissive-avoidant group members tend “to dismiss the benefits of the group, focus on their personal goals versus group goals, and have negative attitudes toward the groups that they belong to” (30). In my experience, some of these individuals felt less flooded by their emotions in online groups. They participated more verbally and were able to connect and become more open online. (Of course, some of these individuals used the online barrier to withdraw and dissociate even more.) Some clients with social anxiety, who are afraid of group criticism and who withdrew from the in-person group, sensed the screen barrier as protective and became more involved when they moved online.
However, not all clients are suitable for online group therapy. Clients with complex relational trauma often struggle greatly with the format, because, for example, the implicit, relational holding is less felt and is more reliant on language. Limbic resonance is much more difficult to achieve online, and this absence affects clients who manifest pre-Oedipal, preverbal conditions more than it affects other clients.
Resistance to Online Group Therapy
In moving from the circle to the screen, resistance from both group members and group leaders can be expected. In most cases, this resistance forms because the online group feels less “real.” However, group leaders are well acquainted with the argument made by members in in-person groups that the relationships in the therapy group are not real. This statement is usually expressed when the therapy becomes more intimate as a way for members to avoid changing their behavior and relationships outside the group by claiming that in reality they cannot develop this level of intimacy. The same interpretation can apply to occurrences when online group members say that the online format and online relationships are not real. Group therapists should distinguish between real obstacles to online communication (which should be acknowledged and validated) and the use of these obstacles to avoid working through psychological difficulties. The following group vignette shows such a case. (A version of this vignette has appeared in a previous publication [28].)
Cathy joined an online group after participating in an intensive workshop with the leader at a conference. In that workshop, she had been impressed by the leader and thought that he had given her special attention. A few months after she joined the weekly online group, she felt disappointed. She did not feel as special as she had felt in the in-person workshop. She said something about losing his attention in the group, but the topic was not explored.
A few weeks later, Cathy wrote to the group leader that she was considering leaving the group, because it was an online group. She said she could not build the connection she was used to creating in an in-person group. She added that not being in the same physical space with other participants at the same time presented a barrier for her. The group leader suggested she bring up this issue for discussion with the group. She agreed, and in the next online session, she told the group that she did not think the online format suited her. Group members’ reactions varied from expressing sorrow, to sadness, to irritation. They did not suggest exploring her motives further. The group leader asked whether that meant that they agreed that the online modality did not allow for real connection. One member suggested that perhaps other issues were blocking her ability to connect. The group leader reminded Cathy how disappointed she had been about not getting enough attention from him and wondered whether that disappointment was more meaningful than she had allowed herself to experience.
Then Nina said, “Cathy, I can see that the connection between you and the group leader is important to you right now, and I want to do whatever I can to help you have it.” Cathy became tearful and was touched by this sacrifice. She shared that in her family, her youngest sister always received her father’s full attention and she painfully longed for him to pay attention to her as well. She was shocked that this group “sister” did not play the role she had expected. All the group members were touched by Nina’s generosity. When the group leader asked Nina whether she could reflect on her motivation, Nina said she understood that Cathy was her “sister” too. At the time of the group therapy, Nina’s father was battling the end stages of cancer, and Nina desperately wanted her own sister to receive validation for her relationship with their father.
Again, sometimes resistance to online groups is valid and based in reality and should be considered seriously. Some barriers to the process cannot be overcome and must merely be tolerated in the service of successful online group work. A lot depends on the ability of group members to tolerate these barriers and to make use of what online groups can offer. We should consider each client separately.
Special consideration should be given to questions of privacy and confidentiality. These issues should not be considered as resistance but as real problems. Group therapists should follow the field’s regulations and legal requirements: the platform they use for online groups should be HIPAA compliant, and they should not practice therapy across state lines. When leading online groups, it is easy to ignore the latest requirement because the Internet has no boundaries. Some of these regulations have been put on hold during the pandemic.
Summary and Conclusions
Online group psychotherapy presents challenges for the group therapist. Therapists must overcome their own resistance to online therapy and help group members to overcome theirs. The main resistance is related to the question of the quality of relationships developed online and to doubt about whether therapeutic alliance can develop online. Bordin’s (6) definition of the working alliance in therapy relates to a mutual agreement on tasks and goals as well as to the establishment of a bond formed by trust, acceptance, and confidence. I hope that this article has brought enough convincing evidence, both from research and experience, that creating this alliance online is possible and that the inevitable obstacles that arise should be dealt with creatively. Group cohesion, an important factor that correlates to positive group outcome, can also be developed online, although it develops more slowly, resulting in longer periods to reach more advanced stages of group therapy.
Moving from the circle to the screen, especially when the group started in person and moved online because of the pandemic, revealed that some group members can benefit more from the online group setting than the in-person setting. In my experience, these members exhibit the dismissive-avoidant attachment style. In addition, my preliminary observation is that some people with intimacy difficulties, social anxiety, and those using dissociative mechanisms may feel protected by the barrier imposed by the screen and may open up more online. However, research about online group psychotherapy using video is lacking, and further research is needed to test these observations.
It is clear that the online group modality is here to stay. In the midst of the COVID-19 pandemic, and as I have been writing this article, some of my group members, who have discovered the comfort of connecting from home, have expressed their desire to continue the group online. The future will probably bring a higher number of online therapy groups, even after the current crisis.
Footnote
The author reports no financial relationships with commercial interests.
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Information & Authors
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Received: 12 July 2020
Revision received: 30 October 2020
Accepted: 11 December 2020
Published online: 2 February 2021
Published in print: June 01, 2021
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Competing Interests
The author has confirmed that details of these cases have been disguised to protect the privacy of the clients described.
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