Attending to Interpersonal Process in Skills-Based Groups
Tracy Zimmerman
The George Washington University Professional Psychology Program
Abstract
This paper explores the relationship between skills-based interventions and interpersonal process in group therapy. Psychotherapy groups typically fall into one of two approaches: skills-based, or interpersonal process-focused. Skills-based groups follow a defined structure, and interventions are focused on teaching specific strategies for more effectively responding to thoughts, feelings, and behaviors, thus reducing symptoms. In contrast, interpersonal process groups are typically unstructured, with interventions focused on increasing insight into interpersonal patterns through communication to and between group members. This paper examines the tension between focusing on skills acquisition versus interpersonal process, examining how each approach contributes to group cohesion and overall therapeutic success. Further, it reflects on the literature for how integration might be approached, and considerations for each approach. The paper argues that a balance between structured skill-building and an awareness of the unconscious interpersonal dynamics in group can lead to a more holistic therapeutic experience, fostering greater group cohesion and engagement, and deeper change. Overall, the assertion is made and supported that each group, regardless of the focus, has an interpersonal process, and if not attended to, the full benefits of the group cannot be harnessed.
Keywords: Skills-based, interpersonal process, group therapy, group technique, group cohesion, therapeutic change, integrative therapy
Introduction
Often, skills-based groups and interpersonal process groups are seen in tension with one another – opposites existing on two ends of a spectrum for group therapy. Many questions emerge for group facilitators who receive training, or see value and have interest, in both skills-based and interpersonal process groups: Are the two methodologies fundamentally at odds with one another? What is gained from each modality, and what is lost? How might one consider and attend to the interpersonal process within a skills-based group? If so, what is gained—and at what cost? What might be lost in a purely skills-based group, and what might be lost in one focused exclusively on interpersonal process? Novice clinicians ponder such questions as they develop their group therapy style, the focus of this article.
Separate Skills-Based and Process Groups
At an Intensive Outpatient Program for Veterans with Serious Mental Illness, each group goes as follows: take attendance, state the group guidelines, review the skill learned last week, introduce a new skill, and practice. The groups span topics from Dialectical Behavioral Therapy (DBT), to Anger Management, to Cognitive Behavioral Therapy (CBT) for Depression, to Ending Self-Stigma, and while the groups are skills-based in nature and intent, group leaders are encouraged to develop their own clinical style in leading group, and manuals are taken as guides rather than absolute truths. I have witnessed firsthand as Veterans learn new skills to navigate and manage their mental illness, relationships, and lives, and how transformational these skills and this program can be for so many. Simultaneously, I find myself holding in mind a multitude of questions as I facilitate and am supervised in these groups: How might we attend to interpersonal process in a skills-based group? If we do, why? What might be lost in a purely skills-based group, and what might be lost in a purely interpersonal process group?
When focusing on skills, group participants build previously unknown strategies and target symptoms to better engage with their world and activities of daily living. One common approach to treating mental illness, particularly severe mental illness, is symptom-focused, with the goal of reducing specific presentations of problems (Yalch et al., 2021). Research has demonstrated that evidence-based therapies do meaningfully reduce symptoms, and, as such, these types of therapies are increasingly developed and applied (Yalch et al., 2021). Tasca et al. (2011) further assert that skills-based groups often lead to increased cohesion as treatment progresses, perhaps because of the group members’ experiences of their symptoms abating. However, as Yalch et al. (2021) report, studies evaluating group evidence-based treatment protocols have often concluded only modest results in reducing psychological distress, which Yalch et al. (2021) hypothesize is because of the focus on a narrow set of symptoms rather than the overall functioning of the person. Further, many might have difficulty completing purely Evidence Based Practice (EBP)-based treatments, as they often entail directly confronting what the individual is struggling with and thus spends much of their time avoiding (Yalch et al., 2021). While there is undoubtedly a rationale and impact of focusing on skills, it may be that, in attending only to skills, something essential to recovery is missed.
Process Groups
In attending to interpersonal process in group therapy, group participants more fully learn about themselves and others, leading to more meaningful relationships and more fulfilling lives. Fonagy et al. (2017) describe how individuals, particularly those with extreme trauma and/or personality disorders, may struggle to trust others, and that this mistrust causes an inability to benefit from social interactions and feedback. This hinders the ability for group to influence beliefs, attitudes, and expectations. As such, they argue, groups must be focused on enhancing the capacity to mentalize and build trust. They assert that key to group work and group cohesion are “interventions that aim to increase mentalizing within the group in the immediacy of the moment” (Fonagy et al. 2017, p. 187). Furthermore, it has been suggested that, at the root of Post Traumatic Stress Disorder (PTSD) are shifts in thoughts about oneself, others, and the world, which influence interpersonal interaction; this underscores the importance of attending to interpersonal factors in treating PTSD (Yalch et al., 2021). That being said, there are additional factors that could limit the efficacy of evidence-based therapies in a group format for PTSD, such as individuals missing sessions and therefore being behind on content, receiving less individual attention and thus understanding suffering, and there being less individual accountability for integral processes such as practice assignments (Resick et al., 2017).
It is clear, according to Tasca et al. (2011)’s findings, that encouraging group members to explore and express their thoughts and feelings in the early stages of group especially, as contrasted to being more directive, led to higher cohesion that established rapport and laid the groundwork for the work to follow. They found that by laying this groundwork in the earlier stages of treatment, patients were more engaged in focusing on content that they had previously avoided, while individuals in a purely skilled-based, structured group were more resistant to the treatment directions offered by the group leader later in treatment. Tasca et al. (2011) conclude that if the group leader in the more skills-based group had engaged in more efforts to understand their patients in the early stages, rather than applying the skills-based interventions aimed at changing behavior so soon, the group could have been more cohesive and open to being challenged in the middle phase, rather than late phase, of treatment.
Alternatively, Fonagy and Luyten (2016) suggest that groups should begin with evidence-based modalities, which provide teaching and learning of content that lowers vigilance. Here, patients learn models for understanding their own experience, which bolsters agency and builds comfort (Fonagy & Luyten, 2016). Following this phase of treatment, patients are increasingly open to social communication, and they show increased interest in the therapist’s mind, thoughts, and feelings, which the therapist reflects back by acknowledging the patient’s experiences and emotional state (Fonagy & Luyten, 2016). As patients increasingly become open to social communication, they can apply this new mentalizing across all areas of their social life, where group work provides an intermediate step in practicing mentalizing and applying social learning beyond the dyadic therapeutic relationship (Fonagy & Luyten, 2016). In summary, Fonagy and Luyten (2016) suggest that providing a more skills-based, structured introduction to group, followed increasingly by a more interpersonal process-based approach, fosters change. This stands in contrast to that suggested by Tasca et al. (2011), where attending to interpersonal process early in group sets the stage for being able to engage more effectively in challenging beliefs, thoughts, and behaviors.
In reflecting on these arguments and approaches, I found myself again considering my own experience where, rather than crafting the structure of the group, I am operating within an existing group structure. As such, I aim to harness the benefits of interpersonal process in creating cohesion and attending more holistically to challenges, alongside the more tactical approaches to building skills, and learning new approaches to thinking, feeling, and relating. To me, this does not necessarily need to be done in phases, but rather, can be done in the moment-to-moment operation of the group.
To elaborate, in my mind, another impact of attending to interpersonal process is enhanced awareness of the unconscious at play in group. One example might be thinking about what group members are holding on behalf of one another. One group member might express a lot of anger, while the rest of the group seems to be euthymic — this might mean that the group member expressing the anger is holding such anger on behalf of the group as a whole. How might we intervene to relieve the single group member from holding all of the anger on behalf of the group? Another example might be taking up questions of power, including as they relate to identity, and noting what is and is not being said, expressed, and communicated. For example, does a member of the group holding predominantly identities associated with power continuously interrupt a group member holding more minority identities? How can we attend to that and intervene?
These dynamics can and will materialize regardless of group format. I would argue that, if a group leader is not aware of the importance of attending to these pieces, inherently they will not, and as such, the group will not benefit from these types of perspectives and interventions. As such, rather than thinking of this work in stages, I think about it in micro-interactions. For example, choosing an intervention aimed at reflecting feelings, rather than challenging thoughts (e.g., the group member expressing anger), or noting who is interrupted, and calling this to the group’s attention rather than simply allowing that encounter to play out. Each group, even a skills-based group, has an interpersonal process, and if this process is not considered and attended to, the group’s impact and efficacy is reduced.
References
Fonagy, P., Campbell, C., & Bateman, A. (2017). Mentalizing, attachment, and epistemic trust in group therapy. International Journal of Group Psychotherapy, 67(2), 176-201. DOI: 10.1080/00207284.2016.1263156
Fonagy, P., & Luyten, P. (2016). A multilevel perspective on the development of borderline personality disorder. In D. Cicchetti (Ed.), Development and psychopathology (3rd ed.). New York, NY: Wiley.
Resick, P.A., Wachen, J.S., Dondanville, K.A., Pruiksma, K.E., Yarvis, J.S., Peterson, A.L., Mintz, J. (2017). Effect of group vs individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder. JAMA Psychiatry, 74(6), 28-37.
Tasca, G., Foot, M., Leite, C., Maxwell, H. (2011). Interpersonal process in psychodynamic-interpersonal and cognitive behavioral group therapy: A systematic case study of two groups. American Psychological Association, 48(3), 260-273. DOI: 10.1037/a0023928
Yalch, M., Burkman, K., Holleran, L., Karpenko, S., Borsari, B. (2021). Integrating collaborative/therapeutic assessment of interpersonal functioning into group therapy for veterans with posttraumatic stress disorder. Journal of Psychotherapy Integration, 31(1), 19-33. DOI: http://dx.doi.org/10.1037/int0000197