ARTICLES

Group Psychotherapy as a Specialty: An

Inconvenient Truth
Martyn Whittingham, Ph.D., Noelle L. Lefforge, Ph.D., ABPP, Cheri Marmarosh, Ph.D.

Group psychology and group psychotherapy (GPGP) are education and training, effectiveness, quality improvement,
distinctive, effective practices that meet an important need. guidelines for delivery, and provider identification and evalu-
In 2018, the American Psychological Association recognized ation) are essential for expanding the availability of high-
GPGP as a specialty, thus setting standards for education quality group psychotherapy. Such understanding also
and training in the field. Although there is a need for high- informs how training programs can align with standards.
quality group psychotherapy, practitioners often lack stan- This article provides a foundation of understanding and de-
dardized training, thus posing a risk to patients. Adoption of tails implications of group psychotherapy’s establishment as
these standards by practice settings and training programs a specialty. The benefits of high-quality group psychothera-
is essential for expanding the availability of quality group py are far-reaching, whereas the risks of inadequate practice
therapy. An understanding of how the specialty became loom large.
recognized and of the specific criteria for its practice (i.e.,
public need, diversity, distinctiveness, advanced scientific Am J Psychother 2021; 74:60–66;
and theoretical preparation, structures and models of doi: 10.1176/appi.psychotherapy.20200037

In 2018, the American Psychological Association’s Commis- than 40% (1), mental health problems were worsening
sion for the Recognition of Specialties and Subspecialties in across a wide range of populations and settings (2). The
Professional Psychology (CRSSPP) recognized group psy- Substance Abuse and Mental Health Services Administra-
chology and group psychotherapy (GPGP) as a specialty. tion’s (SAMHSA’s) 2019 National Survey on Drug Use and
(Formal recognition of group psychotherapy as a specialty Health (3) has shown steady increases in mental disorders,
occurred within the discipline of psychology, but group psy- with increases in major depression, severe mental illness,
chotherapy is practiced by psychiatrists and other mental and any mental illness shown for every age range. Concomi-
health professionals. In this article, the terms “group psy- tantly, opioid addiction is a national epidemic, causing the
chotherapy” or “group therapy” are intended to be inclusive loss of 128 people per day. Mental health diagnoses have
of groups led by all of these professionals.) Although group been rising alarmingly among some age groups, with young
psychotherapy is widely practiced, enhances access to need-
ed treatment, and is a proven treatment modality, some
practice and training sites erroneously believe that it does HIGHLIGHTS
not require specialized training, knowledge, skills, or practi-
ces. The recognition of group psychotherapy as a specialty  Group psychotherapy offers promise in addressing ma-
jor mental health service shortages throughout the
has therefore become an inconvenient truth for those wish-
United States, particularly by providing access to effica-
ing to ignore these training needs. This article outlines what cious care for diverse populations.
a specialty is, how group psychotherapy qualified for spe-  The conduct of group psychotherapy requires special-
cialty status, and the basics of how educational programs ized education and training.
can align with specialty training standards.  Group psychology and group psychotherapy has been
recognized as a specialty by the American Psychologi-
cal Association, which has thus established standards
THE PUBLIC NEED FOR GROUP PSYCHOTHERAPY for education and training.
 Expansion of standardized education and training is need-
U.S. mental health needs have never been greater. Even pri- ed to realize the benefits of group psychotherapy.
or to the COVID-19 pandemic, during which the prevalence
of mental health conditions has increased from 15% to more

60 psychotherapy.psychiatryonline.org Am J Psychother 74:2, 2021

 WHITTINGHAM ET AL.

adults showing in- by SAMHSA (3) for

creases of more than Editor’s Note: This article is part of a special issue on group psycho- addictions treatment,
10% for any mental ill- therapy with Guest Editor Fran Weiss, L.C.S.W.-R., B.C.D. Although and groups are the
authors were invited to submit manuscripts for the themed issue, all
ness and of more than mainstay of many such
articles underwent peer review as per journal policies.
4% for severe mental treatment programs
illness over a 10-year throughout the coun-
period. The second try. Add in the preva-
leading cause of death for individuals ages 15–34 years is lence of therapy groups in skilled nursing facilities,
suicide, with one person dying by suicide every 11 minutes community mental health centers, primary care offices offer-
in the United States (4). ing integrated care, and school settings, and a picture of wide-
The desire to seek services for mental health problems spread utilization emerges. Despite these data, some clinician
has also increased. A recent national study (5) showed that training programs consider group therapy a niche treatment
141 million adults in the United States (56%) have actively and offer little to no training. The utilization data suggest this
sought or wanted to seek treatment for themselves or others reasoning is flawed. Group psychotherapy and group psychol-
they know. Mental health services, however, are both under- ogy are fields with rich histories and a deep base of literature
funded and understaffed (6), and there are not enough clini- and research, as seen in this special issue.
cians to serve the nation’s needs. This deficit has created an
access problem, with one survey finding that, nationally,
VARIABILITY IN TRAINING
only one in four individuals are able to access needed men-
tal health services (5). Access problems have particularly af- Despite group therapy’s potential to improve access to
fected underserved populations, with rural and low-income mental health treatment, training standards remain varied.
areas experiencing lower access to services. (Because the organizations involved in making group psy-
The solutions to these problems are manifold, but provi- chotherapy a specialty were psychology organizations, the
sion of mental health treatment that is efficacious and accessi- standards have applicability only to psychology training pro-
ble is an important part of any national strategy. Group grams and the practice of psychologists, though they likely
therapy offers many solutions to this problem of access to ef- offer value to other disciplines.) A recent survey of agencies
fective treatment by providing the opportunity to improve revealed little attention to group attendance, insufficient
population health by lowering rates of the most prevalent measurement of process and outcomes, and generic supervi-
mental health conditions (6). As a treatment modality, group sion typically serving as the only quality control (20). Anec-
therapy offers evidence-based models of practice and has dotal evidence suggests that many providers and mental
been validated for a wide variety of conditions, including health agency administrators mistakenly believe that group
many of the most prevalent and severe conditions (7), and it is therapy is a treatment delivery system for other therapies,
cost-effective (8, 9). Group psychotherapy also provides bene- rather than a treatment modality itself, and therefore does
fits to culturally diverse populations (10). Specifically, group not require specialist training. The refrain, “If you can do in-
psychotherapy’s effectiveness has been demonstrated across dividual therapy, then you can do group therapy,” is often
the lifespan (see GPGP Specialty Council Petition [11] for rele- heard in training and practice settings. This is a mistaken as-
vant citations), among ethnically diverse populations (12), sumption. Achieving GPGP specialty status required demon-
among those with diverse gender and sexual orientations (13, strating that GPGP has unique processes, techniques, and
14), and among special populations, including patients with evidence bases. Without this foundation, unqualified and un-
HIV/AIDS (15), veterans (11), and incarcerated persons (9, 16). skilled practitioners are left to lead groups with inadequate
preparation, little understanding of group dynamics, lack of
knowledge or skills to intervene, and little discernible ac-
UTILIZATION OF GROUP THERAPY
countability for outcomes. Without specialized expertise,
Group therapy utilization is difficult to determine at the na- group psychotherapists can both contribute to and fail to
tional level because data sets are dispersed across multiple mitigate adverse outcomes (21).
payment sources and agency providers and are not always
available to the public. However, the data available suggest
WHAT IS A SPECIALTY AND WHO QUALIFIES AS
widespread usage of group therapy as a primary or adjunctive
A SPECIALIST?
treatment across a wide range of settings. Medicare data indi-
cate that group therapy is the second most utilized psycho- The CRSSPP was established within the American Psycho-
therapy nationally (17). Moreover, group therapy is the logical Association to “identify, codify by recognition, and
dominant treatment modality within the Veterans Health Ad- clarify for the public distinctive patterns of education, train-
ministration (18). Surveys of utilization in prisons, which ing, and practice that exist among professional psy-
house the nation’s largest number of mental health patients, chologists” (22). The CRSSPP states that, “A specialty is a
have shown (19) that group therapy is used for at least 20% defined area of professional psychology practice character-
of their services. Group psychotherapy is also recommended ized by a distinctive configuration of competent services for

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GROUP PSYCHOTHERAPY AS A SPECIALTY

specified problems and populations. Practice in a specialty criteria, which GPGP was required to meet (11). Many of
requires advanced knowledge and skills acquired through these criteria are beyond the scope of this article or have
an organized sequence of formal education, training, and ex- been discussed above. However, the criteria that explain is-
perience in addition to the broad and general education and sues such as diversity (criterion III), the distinctiveness of
core scientific and professional foundations” (23). Thus, spe- group therapy (criterion IV) and training standards at each
cialty recognition applies to training, which is acquired dur- level of training (criteria V, VI, and VII) are germane to this
ing psychology doctoral programs, internships, postdoctoral article’s purpose—to describe the rationale for the specialty
fellowships, and/or at the postlicensure level and which designation and to indicate training standards that programs
must go beyond the generalist training expected at each should consider—and are discussed below.
level. Training programs are therefore the focus of this arti-
cle. The CRSSPP recognizes specialties related to the direct Diversity (Criterion III)
provision of health services and those related to the provi- Training and practice issues in diversity have become ever
sion of applied professional services. more important to the mental health field, and group therapy
Although the CRSSPP recognizes specialties at the training can uniquely contribute to this area. Although general training
program level, it does not credential individual psychologists is expected to prepare group psychotherapists to practice in ac-
nor limit their practice. Instead, licensing boards, legislation cordance with the American Psychological Association’s multi-
and other regulations, and ethical principles and codes of con- cultural guidelines (26) and professional practice guidelines
duct regulate the practice of individual psychologists in the applicable to practice with particular populations (see https://
same way they regulate the practice of psychiatrists and other www.apa.org/practice/guidelines), multicultural training and
mental health practitioners. In addition to CRSSPP’s ability to competence specific to GPGP go beyond this routine training.
recognize specialties, it also recognizes organizations that cer- An example of GPGP-specific diversity training is the iden-
tify individuals in recognized specialties, such as the American tified need to train group psychotherapists to be able to re-
Board of Professional Psychology (ABPP). spond to microaggressions in groups. Microaggressions have
Although the focus of this article is not on specialty been studied in other modalities of psychotherapy (27), and
credentialing at the individual level, individuals interested in their harmfulness has been clearly established. Microaggres-
receiving recognition for competence or mastery can learn sions in group psychotherapy are complex and pose increased
more about the two existing credentials. These credentials risk of harm, because often there can be multiple perpetrators,
are conferred by the ABPP, which offers board certification targets, and/or bystanders present and exponentially more
for psychologists in GPGP that is recognized by the CRSSPP factors influencing the group psychotherapist’s response (28).
(https://www.abpp.org/Applicant-Information/Specialty-Boards/ Accordingly, a growing body of literature has addressed mi-
Group-Psychology.aspx) and by the International Board for croaggressions in group psychotherapy (29), continuing edu-
Certification of Group Psychotherapists (https://www. cation has offered increased opportunities to train group
agpa.org/cgp-certification/), an entity of the American psychotherapists to respond to microaggressions in group psy-
Group Psychotherapy Association (AGPA), which certifies chotherapy (30), and relevant GPGP competencies have been
candidates from almost all mental health disciplines and developed, including demonstration of the ability to effectively
offers the Certified Group Psychotherapist credential. intervene when microaggressions occur in a group (31). The
nuances of leader-member, member-member, and member-
group interactions add complexity to interventions, thus re-
ESTABLISHMENT OF THE GPGP SPECIALTY
quiring skills from the group leader beyond those provided in
GPGP is unique in that it combines two areas that differ in individual psychotherapy training.
their type of service provision. Group psychologists typically
provide applied professional services, whereas group psycho- Distinctiveness (Criterion IV)
therapists typically provide health services. Because the The CRSSPP also requires specialties to demonstrate how
American Psychological Association recognizes specialties in they are distinct from one another. GPGP has distinctive
either type of service, training programs in group psychology, theoretical underpinnings (32). Although there is overlap
group psychotherapy, or both are eligible for recognition. with other mental health specialties (e.g., clinical, counsel-
However, because the American Psychological Association ing) in the populations treated, GPGP uses distinct techni-
only accredits programs in health service psychology, the ques and procedures. The group-specific therapeutic factors
standards for education and training are more clearly estab- (33) and mechanisms of change (34) of group psychotherapy
lished for programs in this area (4). Although the GPGP- are examples of the depth and breadth of constructs operat-
approved specialty petition places greater emphasis on group ing within any group. Therapeutic factors in group therapy,
psychotherapy than on group psychology, work is increasing such as group cohesion and interpersonal skills, interact in
to better integrate these areas (24). complex ways with group dynamics, leadership skills, set-
The CRSSPP established 12 criteria (25) needed to ting, and treatment type. Group psychotherapists must have
achieve specialty status as well as an application and renew- intervention skills that are able to address those complexi-
al process by which a field can establish that it meets these ties (33, 35). As Yalom and Leszcz (33) have suggested,

62 psychotherapy.psychiatryonline.org Am J Psychother 74:2, 2021

 WHITTINGHAM ET AL.

TABLE 1. Stages of group psychology and group psychotherapy traininga

Stages of education and training
Level of training Doctoral Internship Postdoctoral Postlicensure
Major area 96 hours didactics, Didactics (see doctoral); 80%–100% of residency 50 hours organized CE,
of study between doctorate and 50 hours as facilitator to include didactics, 50 direct hours with
internship to include or cofacilitator and 30 clinical practice, supervision in
practicum hours supervision supervision, and specialty
presentations
Emphasis 48 hours coursework and N/A 30%–50% didactics on 25 hours organized CE,
supervised practicum advanced group direct clinical contact
as group leader or leadership, clinical with supervision in
group coleader issues, supervised specialty
experiences
Experience 20 hours didactics and 10 N/A 20%–29% didactics on Some CE at conference
hours as a training advanced group with part-time
group member leadership, clinical (supervised) practice
issues, supervised in specialty
experiences
Exposure 1 entry-level group N/A ,20% didactics on Some CE on clinical
course advanced group aspects of practice or
leadership, clinical university course in
issues, supervised specialty
experiences
a
Source: Group Psychology and Group Psychotherapy Specialty Council Petition (11). CE, continuing education. N/A, not applicable.

premature dropout, which can result from failure to manage overviews of group efficacy research and illustrate the
these complexities, can result in double demoralization, be- breadth and depth of the literature related to this specialty.
cause already demoralized patients often experienced wors-
ened symptoms after feeling they have failed at the
SPECIALTY ACCREDITATION AND ALIGNMENT OF
treatment meant to help them. Put simply, group therapy,
TRAINING PROGRAMS
like other therapies, can be iatrogenic when led poorly.
A growing body of evidence has shown the benefits of the As previously mentioned, group leader training is ripe for im-
use of specialized assessment in group therapy (36, 37) to aug- provement, with sites and institutions varying widely in the
ment clinical judgment. Group therapy–specific assessment quality and quantity of their offerings (48). Although there are
tools enhance the group leader’s ability to assess group readi- excellent programs for group therapy (e.g., Brigham Young
ness (e.g., Group Readiness Questionnaire [38]), monitor group University’s Counseling Center and Harvard University–affili-
process (e.g., Group Questionnaire [39]), and assess factors af- ated McLean Hospital), there is wide variation in the quality
fecting screening, process, and outcomes, such as interperson- of practice across settings and populations. Few programs
al distress (e.g., Inventory of Interpersonal Problems [40]). have clear standards for staff in terms of training and prepara-
These tools, which can be used as part of an evidence-based tion in group psychotherapy, other than reliance on licensure.
practice approach to enhance therapy in real time, formed Approval of GPGP as a specialty set the standards for remedy-
part of the case for achieving specialty status (11). ing this situation. The following guidelines and standards are
germane to the process of offering specialty training.

Effectiveness and Quality Improvement (Criteria IX Practice Guidelines (Criterion XI)

and X) GPGP practice guidelines exist under several organizations.
The CRSSPP also requires specialties to support the effec- Most salient to the American Psychological Association’s
tiveness of their practice and to demonstrate that such in- recognition of GPGP as a specialty are the Association’s Divi-
vestigation is ongoing. Rosendahl et al.’s review of research sion 49 Clinical Practice Guidelines (49), which are current-
in this special issue (41) sheds light on the empirical inquiry ly in draft form and can be found online. Division 49’s GPGP
taking place nationally and internationally. Group psycho- Specialty Council’s strategic objectives include finalization
therapy has been shown to be as effective as individual ther- of these practice guidelines. Previously, AGPA’s Science to
apy for most patients and disorders (42, 43). Moreover, an Service Task Force had published practice guidelines for
increasing body of meta-analyses have supported the effica- group psychotherapy (50); efforts to update these guidelines
cy of group psychotherapy for particular disorders, such as are also underway. Finally, the Association for Specialists in
anxiety (44) and depression (45), and research on therapeu- Group Work has also released practice guidelines (51). There
tic factors, such as the impact of group cohesion on outcome is extensive alignment among all these guidelines. The
(46), is ongoing. Systematic reviews (47) also provide helpful guidelines have been designed to inform training programs

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GROUP PSYCHOTHERAPY AS A SPECIALTY

about material that would be suitable for training clinicians recognized for providing specialty training to potential
and can therefore serve as a guide for those wishing to offer trainees and the group psychology and psychotherapy
specialty training. community.

Training Guidelines
CONCLUSIONS
Training programs at each training level (i.e., doctoral, in-
ternship, postdoctoral, and postlicensure) of psychology The future of quality improvement in the field requires train-
training are able to promote their GPGP specialty training if ing and practice settings to embrace the need for specialized
they can demonstrate their alignment with the standards training in group therapy. With more sites adopting training
laid out in criteria V, VI, and VII and in the GPGP Educa- standards, specialty status provides the opportunity to im-
tion and Training Guidelines. (The current GPGP guidelines prove patient access and outcomes through the provision of
can be found at https://www.apadivisions.org/division-49/ enhanced leadership skills among practitioners. Training pro-
leadership/committees/group-specialty; the guidelines will grams aligning with standards for education and training in
be reformulated in a pending manuscript that is being devel- GPGP have an opportunity to join the efforts to promote high-
oped under the auspices of the GPGP Specialty Council.) quality outcomes in group therapy by showcasing their com-
mitment to evidence-based work. Programs that provide
Taxonomy comprehensive group specialty training are vindicated in that
The American Psychological Association has developed a choice and present an inconvenient truth to those seeking to
taxonomy (25) to provide an organizing framework and con- relegate group practice to the untrained.
sistent terminology for education and training in psychology
health services specialties. In particular, these guidelines en-
AUTHOR AND ARTICLE INFORMATION
courage education and training programs to use the follow-
Chicago School of Professional Psychology, Washington, D.C.
ing terminology when referring to their specialty training:
(Whittingham); Graduate School of Professional Psychology, University
major area of study, emphasis, experience, and exposure. of Denver, Denver (Lefforge); Professional Psychology Program,
Programs that offer GPGP must comply with the taxonomy George Washington University, Washington, D.C. (Marmarosh).
(Table 1). Additionally, specialty accreditation (52) for post- Send correspondence to Dr. Whittingham (mswhittingham100@outlook.
doctoral residency programs is defined by the American com).
Psychological Association through their Council on Accredi- Received August 10, 2020; revisions received November 13, 2020, and
tation, which is currently awaiting recognition. January 23, March 5, and March 20, 2021; accepted March 24, 2020;
published online June 2, 2021.

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