Between Systems and Selves: Identity, Fit, and Reflexivity in Group Psychotherapy
Omaya Kharboutli, MSc
Doctoral Student in Clinical Psychology
Professional Psychology Program, The George Washington University
Abstract
As I reflect on my development as a group therapist, I find myself shaped by living and training across three different systems and countries: Lebanon, the United Kingdom, and now the United States. When I first began co-facilitating groups in Lebanon for undergraduate students during the COVID-19 pandemic and for survivors following the 2020 Beirut blast, I observed how groups could foster safety and connection during crises (Hobfoll et al., 2007; Ruzek et al., 2007; World Health Organization, 2011). Later, working on an inpatient eating disorder unit in London, I learned how structured Dialectical Behavior Therapy (DBT) groups can provide patients with strategies for managing distress while also reducing shame and fostering universality (Linehan, 2015; Yalom & Leszcz, 2020). Now, as a doctoral student in a psychodynamically oriented clinical psychology program in the United States, I am learning to sit with ambiguity, unconscious dynamics, and the circulation of power in groups.
Together, these contexts have shaped how I think about belonging, safety, and responsibility as a leader. They also raise questions of fit and reflexivity: How do we match structure and process to members’ needs? How do our own identities shape transference, countertransference, and the group’s culture? This reflection considers those questions, situating my experiences alongside the literature on group psychotherapy to explore what they might mean for clinical practice.
Keywords: group psychotherapy, treatment fit, therapist reflexivity, group leadership, interpersonal dynamics, identity in psychotherapy
Structure, Process, and the Question of Fit
The privilege of learning about both cognitive-behavioral and third-wave therapies, as well as psychodynamic and psychoanalytic approaches, has underscored a central task for group leaders: discerning which therapeutic approach fits a client at a given time. For many individuals, particularly those experiencing acute distress, heightened anxiety, or limited tolerance for ambiguity, structured group formats can offer a predictable therapeutic frame that supports engagement and cohesion (Burlingame et al., 2011; Yalom & Leszcz, 2020). In practice, these may include skills-based, psychoeducational, cognitive-behavioral, or other manualized group therapy formats. These structured interventions can promote stabilization and the development of emotion regulation and interpersonal skills that support readiness for more exploratory group work (Linehan, 2015; Yalom & Leszcz, 2020).
Once that foundation is in place, psychodynamic and interpersonal process groups may become clinically appropriate. These groups invite members to engage more directly with affect, transference, rupture, and repair, allowing relational patterns—individual, interpersonal, and systemic—to emerge in vivo and be worked through collaboratively (Marmarosh et al., 2022; Yalom & Leszcz, 2020). As Yalom and Leszcz (2020) emphasize in their discussion of client selection and group composition, not every member is ready for every type of group. Clients who are easily overwhelmed by affect or who struggle with unstructured interpersonal environments may benefit from beginning in structured group formats before transitioning into interpersonal process groups, where ambiguity and unconscious dynamics are more central. From this perspective, structured groups function not as a lesser intervention, but as a clinically strategic entry point that can prepare members for the relational depth of psychodynamic group work.
For example, in the aftermath of the Beirut blast, I co-facilitated skills-oriented, structured walk-in support groups at a walk-in mental health clinic within the blast-impacted area as part of the wider psychosocial response (Brown et al., 2024). Informed by Mental Health and Psychosocial Support (MHPSS) principles and Psychological First Aid (PFA), our group supported members to identify internal and external safety anchors, regulate physiological arousal, and share coping strategies amid collective loss (Inter-Agency Standing Committee, 2007; Ruzek et al., 2007; World Health Organization, 2011). At the time, I understoodthese group interventions primarily as crisis-stabilizing, oriented toward immediate safety, grounding, and functional support; subsequent reflection and training in group psychotherapy clarified how such structured formats can also support the restoration of internal and relational safety, thereby creating the conditions under which reflective capacity and group engagement may later emerge (Yalom & Leszcz, 2020). The inpatient skills-based groups I co-facilitated on an eating disorder service in London were grounded in Dialectical Behavior Therapy and used a different form of structure and containment through repeated skills practice. These groups focused on strengthening mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness skills (Linehan, 2015). My initial training reactions to the DBT model included a concern that the emphasis on skills acquisition might constrain spontaneity or deeper relational engagement. Over time, however, I observed that the predictability and active skill rehearsal expanded members’ window of tolerance, enabling greater affect regulation and increased capacity to remain present in interpersonal contexts (Siegel, 1999).
Taken together, these experiences illustrate how structured group formats can serve distinct yet complementary clinical functions depending on context and population. The post-disaster groups primarily aimed to re-establish a fragile sense of safety and orientation in the immediate aftermath of trauma (Ruzek et al., 2007), whereas the inpatient DBT groups focused on cultivating ongoing self-regulatory capacities and mindful awareness to support longer-term psychological work (Linehan, 2015; Siegel, 1999). In both cases, structure functioned as a stabilizing scaffold—though in service of different therapeutic aims—reinforcing the importance of aligning group format with client readiness and clinical context.
Treatment Fit in Borderline Personality Disorder (BPD) Group Psychotherapy
Another dimension of group member fit relates to the treatment model or approach that fosters change. The psychotherapy literature on BPD illustrates this well. BPD is among the widely studied conditions in psychotherapy research, with multiple evidence-based treatments tested in individual and group formats (Storebø et al., 2020). A recent network meta-analysis of 43 randomized controlled trials (RCTs) investigated the comparative efficacy of specialized psychotherapies for adults with (sub)clinical BPD (Setkowski et al., 2023). Specialized therapies (e.g., DBT, Mentalization-Based Therapy (MBT; Bateman & Fonagy, 2016), and Schema Therapy (ST; Young et al., 2003) were compared with treatment-as-usual (TAU, e.g., case management, pharmacological support, or supportive counseling) and generic psychotherapy (GT). Interventions were delivered in individual (n=13), group (n=6), or combined formats (n=23). Across studies, specialized treatments were significantly more effective than TAU and GT, but therapeutic modality did not significantly moderate BPD symptom severity. While ST showed somewhat larger effects than cognitive-behavioral and psychodynamic therapies, those findings were based on only 3 RCTs. The authors concluded that no single modality appears superior and called for high-quality, head-to-head RCTs and individual patient data meta-analyses to identify moderators of treatment response (Setkowski et al., 2023).
Further evidence from group-based interventions underscores the heterogeneity of effective modalities. In a meta-analysis of 16 RCTs, group psychotherapy for BPD showed a large overall effect size (Hedges’ g ≈ 0.72) relative to TAU, wait-list, or supportive therapy, improving BPD symptoms (McLaughlin, et al., 2019). Theoretical orientation — whether DBT, Acceptance and Commitment Therapy (ACT; Hayes et al., 1999), interpersonal, or psychodynamic—did not moderate BPD symptoms. Notably, ACT was the only other orientation demonstrating consistently higher effect sizes across both BPD symptoms and suicidality outcomes compared with DBT, though these findings were based on only 3 ACT studies versus 14 DBT studies, warranting caution in interpretation (McLaughlin et al., 2019). The authors noted that their analysis of theoretical orientation was limited by the small number of included studies (McLaughlin et al., 2019).
An emerging body of literature on group therapy in BPD is also exploring mechanism-focused interventions and their effectiveness in targeting specific behavioral domains in BPD. Aggression in BPD is conceptualized as emerging from real or perceived social threat, frustration, or rejection, underpinned by mechanisms including threat hypersensitivity, deficits in anger regulation and mentalizing, and increased emotional contagion (Gardner et al., 2012; Mancke et al., 2015). Drawing on these factors, Herpertz and colleagues (2021) developed mechanism-based anti-aggression psychotherapy (MAAP), a group intervention designed to address these processes by combining elements of DBT skills training and MBT techniques. In a cluster RCT, MAAP led to clinically significant reductions in aggression and impulsivity compared to non-specific supportive psychotherapy (Herpertz et al., 2021).
The heterogeneity of the evidence suggests that multiple group therapy modalities can alleviate BPD symptoms through distinct mechanisms: behavioral regulation and skills acquisition in DBT and MAAP; mentalization in MBT; cognitive-affective restructuring in ST; and psychological flexibility and values-based action in ACT. We can therefore conclude that no single group psychotherapy modality holds absolute superiority in the treatment of BPD. Rather, multiple approaches appear capable of producing meaningful change through different, theoretically coherent mechanisms. Importantly, the absence of consistent modality effects across both individual and group formats indicates that treatment outcome is not determined by diagnosis alone, but by the alignment between a group’s therapeutic demands, members’ current capacities, and the clinician’s theoretical orientation and skill set. In this sense, BPD serves as a particularly well-studied example of a broader principle in group psychotherapy: effective treatment depends less on adherence to a universally “best” model and more on the clinician’s capacity to use a modality competently, flexibly, and in accordance with the developmental readiness of the group (Marmarosh et al., 2022; Yalom & Leszcz, 2020). From this perspective, treatment fit in group psychotherapy is a dynamic, relational decision—shaped jointly by client needs, group context, and therapist orientation—rather than a diagnosis-driven prescription.
Reflexivity in Leadership
Evidence about what works for whom only goes so far without the leader’s reflexivity about identity, power, and countertransference. Training in both U.S.- and U.K.-based programs while working with Western and non-Western clients, I sit as a Lebanese Middle Eastern female clinician-in-training, working within evidence-based frameworks rooted in Western traditions. Reflecting on how these models align or conflict with cultural and community-based understandings of mental health outside of Euro-American settings, I realized positioning keeps me alert to how culture, nationality, linguistics, migration, and institutional oppression shape experience. I also recognize how those inequities are present in groups (Debiak, 2007; Hays, 2008).
I am learning that holding both marginalized and privileged identities can make my presence feel protective for some group members while distancing for others. For example, in a post-meal support group I co-facilitated, a female member shared about longstanding shame related to her body, noting that she had avoided discussing it in mixed-gender settings. She stated that it felt more possible to raise the topic “with another woman facilitating the group.” Her disclosure invited other group members to share body-related self-criticism with greater openness, and the group shifted from general discussions of self-esteem to more specific material. This interaction sharpened my awareness of how gendered identification can influence what members experience as speakable in a group, and how a leader’s identity influences the emotional risks members are willing to take. In contrast, in another group on the ward, frustration emerged around treatment routines and was directed toward me as a member of the clinical team. Several members addressed their concerns to me rather than to one another, questioning policies and expressing frustration about clinical decisions made by senior clinicians. This shift highlighted how institutional authority can become condensed in the group leader, shaping affective expression and requiring leaders’ attention to power and transference dynamics.
These contrasting reactions have underscored for me that holding intersecting identities is a relational variable that shifts across group contexts and compositions. Attending to these dynamics is part of safeguarding the group as a therapeutic space: when leaders fail to acknowledge identity and power, groups risk replicating systemic inequities (Debiak, 2007; Gitterman, 2019). Yet when engaged thoughtfully, those same dynamics can become points of connection, repair, and cohesion, modeling for members that difference can be named and held beyond rupture (Bemak & Chung, 2019).
The Transition I Am In
One of the challenges I am working with in my first semester of doctoral training is my capacity to sit with uncertainty. Having trained in more structured group settings, where the leader’s role emphasized guiding skills practice and maintaining containment, I have had to confront my discomfort when sessions unfold without clear direction or immediate resolution. While watching tapes of demoed process-oriented groups in classes, I noticed in myself a strong vicarious pull to intervene—by summarizing, redirecting, or offering structure—particularly when silences lengthened or when affect intensified without an obvious path forward. Resisting this impulse required tolerating not only the group’s uncertainty, but my own anxiety about whether I would be “doing enough” if I were the leader.
In several instances, choosing not to intervene altered the course of the group in ways I would not have anticipated. Through moments of silence or unresolved tension, members gradually began to name their own reactions, sometimes articulating concerns about being misunderstood, ignored, or judged by the group. These exchanges revealed relational patterns that might have remained obscured had the leader moved too quickly to contain or organize the discussion. I came to understand that sitting with uncertainty is an active clinical decision that allowed the group’s meaning-making processes to emerge organically (Ribeiro, 2020). I have encountered similar uncertainty in my own clinical group work, particularly when members voiced frustration with one another and turned toward me expectantly for guidance. Rather than resolving the tension for the group, I intervened by naming what was happening and opening the space for members to respond directly to one another, inviting them to share their reactions while I maintained the frame. This allowed the group to remain with the discomfort and engage relationally, rather than locating resolution solely in me as the leader.
Reflecting on these experiences has helped me understand how structure and process function as complementary threads rather than opposing ones. Containment can create the conditions for safety, but it is the leader’s capacity to tolerate ambiguity—alongside the group—that allows members to engage more with discomfort and discover their collective resources for meaning-making and therapeutic change (Ribeiro, 2020; Yalom & Leszcz, 2020).
Conclusion: Shared Questions, Evolving Identities
Writing this reflection, I realize my story is not only about how I trained but about how identity, culture, and evidence interact in the reflexive task of becoming a group leader. Some trainees and early-career clinicians may find themselves making similar transitions across orientations, integrating prior learning with what the present moment calls for, and discovering their group leader identity within wider social and institutional contexts. I offer this reflection to contribute to a wider dialogue: leadership in groups is an evolving process —shaped by context, sustained by reflection, and strengthened by our courage to enter therapeutic spaces with openness, humility, and respect.
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