President’s Column

Group as a Specialty

Martyn Whittingham describes the need for training in group psychotherapy to improve outcomes.
By Martyn Whittingham

Martyn Whittingham, PhD We are approaching the time for APA convention, which this year takes place in Chicago, Aug. 8-11, 2019. We look forward to seeing you there and hope you can come visit us either for presentations, at the business meetings or at the social hour (PDF, 1.6MB). We have a small but energetic group of folks, and we punch well above our weight as a division with a gold standard journal and a national impact on the field of psychotherapy. If you are looking for a home, we are a good place to meet people, as our members are a warm and inviting group who love to be around people (unsurprisingly, given our members’ interests). 

A few words about what our division leadership has been working on to advance the Society’s interests. First, we recently had a feature in the APA’s Monitor, outlining the contemporary advances in group and alerting psychologists about some important tips for good group practice. Second, we have been working behind the scenes to make strong connections with the APA Practice Directorate so we can move forward on promoting group as a specialty. In particular, we are positioning our members to effectively advocate for required group therapy training in graduate programs and beyond, as well as to ensure Centers for Medicare and Medicaid Services (CMS) understands the role group can play in value-based payment systems as a means to promote access and outcomes. 

As I have mentioned in this column before, group therapy and group psychology are uniquely positioned to take a leading role in health care and mental health. The only thing that is missing is awareness and training. In my presidential address at APA’s convention, I will be discussing what the data shows about utilization of group therapy nationwide. Spoiler alert: It is much more widely used than people suppose and in some major workplaces where psychologists practice, forms the primary treatment modality. Therefore, we need to become stronger in advocating for rigorous training in this modality. It is a specialty requiring specialty training, and it is not a niche practice. Without specialty training, outcomes can be dramatically worse for a very large segment of the population being treated. My challenge to you as you read this column is to see if your program requires group therapy and if not, gather the necessary data to make the case to any program you are affiliated with. We need group therapy training to be required, not an elective or completely ignored.

While working in a previous position, I was responsible for the quality of group therapy provision across multiple inpatient and outpatient units. Several things became apparent as I worked. First, there is not always a good relationship between practitioners’ self-described competence and their actual effectiveness. Some group therapists were confident in their skills and some were not. However, the ones most certain of their expertise often proved to show the least effective outcomes when measured. Once formal evaluation took place, clear differences emerged between the outcomes of sites, even after initial severity was controlled for. Frequently, it was the poorer performing sites that had the most confident therapists and vice versa. There is a lot to be said for humility and a willingness to learn and grow. Secondly, training made a huge difference. Over two years, we initiated multiple training methods, ranging from on-site supervision to workshops, requiring the Certification in Group Psychotherapy from AGPA, telepresence training, adherence checklists, watching videos and readings. Over time, this made a huge difference. By the end of two and a half years, admission to discharge change scores had changed at significant levels. Training and ongoing supervision and quality improvement were key components. The successful improvement in outcomes was a function of not just teaching a specific model but also in providing generalist training and supervision in the evidence-based techniques in group.

This was an exemplar of the need for the field to fully embrace group as a specialty and to require classes and trainings at the pre and post-doctoral levels. There are too many programs and practice settings relying on the assumption that group is just individual therapy with more people and that more, unsupervised experience in group will ensure results. This is simply not true. I have seen too many practitioners with sometimes decades of experience make what seem like “rookie” mistakes. They have often been thrown in at the deep end, found a way of working that is uncritiqued and ended up practicing group for twenty years while making the same mistakes as in year one. 

I am tempted to call this hubris, but in reality it is just people trying their best with what they know to do a good job. However, we know that training is out there that can make a difference in outcomes. Where hubris becomes an issue is in decision-makers about training failing to recognize that group is not easy.  It requires considerable time, supervision and feedback to improve quality. Specialty designation recognizes that leading groups requires skills that are unique to group therapy. As a field, we need to embrace that group therapy can be effective, efficient and improve access to mental health treatment. However, in doing so, we also need to embrace the concept that training in its methods and techniques is an essential component that should be mandatory in every program.

If you are part of a program or practice or even working individually, we would love to continue this and other discussions to see how we can work together on moving group forward. If you see us at the convention, say hello and introduce yourself. We would love to meet you and see how we can help you in your career goals. Looking forward to seeing you in Chicago.