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This Padlet aims to address the specific needs of people experiencing depression through group work intervention. Depression is a common illness, with one in five people experiencing a depressive episode in their lifetime. The World Health Organization projects depression to be the leading cause of disease by 2030 (6). Depression has no cure and is currently treated by one or a variety of four interventions; psychosocial support, psychological therapy, pharmacotherapy, and electroconvulsive therapy (6). Therapeutic group work is classified as a mixed psychosocial, and psychological intervention (6). Treatment of depression has limited long-term success rates, and the incorporation of group therapy can improve these outcomes. Meta-analyses of group psychotherapy and cognitive behavioural therapy outcomes reveal that group therapy is a cost-effective treatment method that is no less effective than individual therapy for people experiencing depression (7). Therapeutic group work for this population is an economical method of delivering treatment by integrating costly psychological therapy while simultaneously providing psychosocial support (7). Furthermore, this population also benefits from the ancillary benefit of learning more about depression during the process.

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Individuals experiencing depression lack adequate information and the accompanying understanding of effective strategies to address the difficulties that arise when symptoms of depression exist (2). This target group needs access to quality information and trained professionals (2). Group therapy is an economically viable mechanism for professionals to disseminate valuable information to those with depression.

Unfortunately, the stigmatization of mental illness is a barrier for many in seeking professional advice and treatment (2). Mental health professionals are well equipped to provide information to people experiencing depression; however, it remains common to avoid professional help with mental illness (2). Increasingly, online support groups have become a source of support for people who are reluctant to seek community-based resources, which speaks to the needs of those who are depressed to receive guidance from others who are also experiencing depression. Although trained facilitators produce the best results in group therapy for depression, online support remains a relevant resource for those who are reluctant to seek help in the community (5). The proactivity of those who seek online support is an identifiable strength in this population. However; as this is such a broad target group, identifying strengths might be more appropriate on an individual level.

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For people experiencing depression, effective group therapy is conducted in a small, closed group, time-limited, face-to-face format (5, 10). Therapeutic groups for this population should involve elements of psychotherapy or cognitive behavioural therapy (CBT) (1, 12). Psychotherapy and CBT are well-regarded methods of therapeutic intervention for depression. When offered in a group setting, the benefits are expanded on by the dynamics of group cohesion and normalization (10). These group effects allow members to learn from one another and function as co-therapists integrating psychosocial intervention in the treatment process (12). Combining educational components within therapeutic group work also elicits positive long-term outcomes for this population (1). The emotional vulnerability of the target population warrants keeping groups closed to foster security and safety, to support the efficacy of group work with this population (1,10).

Alternatively, groups designed this way do not allow for individualized interventions, which can be problematic for this population because of the breadth of potential symptoms, experiences, and underlying causes of depression (1, 12).

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In a therapeutic setting with group members who experience depression, facilitators function as role models for the group and are tasked with managing each member's experience within the group dynamic (10,13). Effective modelling of interpersonal communication skills is educational for members and aids them in understanding how to participate and set boundaries. Effective facilitation with a group experiencing depression also requires the leader to possess unconditional positive regard, which fosters a safe environment where each member feels validated in their personal experience and for their contribution to the group (13). Although the facilitator is the primary connection each member has with the group, their goal should be to enable the group to interact effectively and create an environment where the group becomes invested in their collective goals. This culture can be fostered by establishing confidentiality, goals, expectations, using affirming and empathetic statements, encouraging collaboration and orienting the group to the present (8,10).

Facilitating evidence-based therapeutic group work is a highly specialized skill that requires special training (8). Commonly, therapists are not equipped to address the needs of group dynamics. Facilitators can best serve those experiencing depression by understanding group development, stages and dynamics to encourage group cohesion and effectively address conflict and diversity (8,10).

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Anti-oppressive practice in group therapy with people experiencing depression requires considering where power issues arise in this target group. Issues of power and oppression arise for people receiving mental health treatment when their cultural background or experience of marginalization is unaddressed, unexplored, or undermined (4,11). Interventions that exalt the lens and theory of the dominant culture to understand depression when working with marginalized people perpetuates oppression (4,11). In Canada, the colonization of Indigenous People’s often contextualizes their experience with depression. Therefore, the epistemology of psychology should be critically analyzed to reduce the chance that it is applied hegemonically to people experiencing depression (11).

Disempowerment in the field of mental health can also arise from an over-emphasis of the professional-to-client relationship rather than a person-to-person relationship. Group facilitators should reflect on their attitudes and those of their organization to identify disempowering and paternalistic attitudes and policies (4,11). Should a facilitator find themselves working in a manner that perpetuates oppression, they can mitigate group therapy members experience of this by (4):

Reducing or eliminating the use of hierarchical position    titles

Being transparent about all aspects of mental health

Minimizing the use of diagnostic labels

Remaining honest about limitations and using self-disclosure appropriately

Expressing openness to feedback on issues of oppression

Practicing critical self-reflection

Identifying strengths and unique qualities in place of an emphasis on members as recipients of a service

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Group therapy sessions with proven efficacy for depression are commonly scheduled for 12 weeks with weekly hour-long sessions of 5 to 7 participants. Group member recruitment can occur in community health and primary care settings. However, group therapy with this target group is less effective when conducted in a clinical setting. Non-clinical settings, like universities or community centres, are preferred (4,12).

High dropout rates are the most significant challenge to successful group therapy for people experiencing depression, and attrition interferes with the efficacy of group work for those who remain (1,7). Group members should be individually assessed for their suitability to and understanding of group therapy (10,13). Preparation and suitability screening reduces the likelihood of drop-out, supporting early development and cohesion for this population (10). Not everyone experiencing depression is a suitable candidate for group therapy, especially if their circumstances create barriers to their ability to focus on others (10,13). For example, recent survivors of sexual assault in this target group are more likely to succeed in one-on-one therapy before participating in group therapy (13).

Depression occurs in every demographic and can impact people differently; therefore, group composition also needs consideration. Group therapy with this population is more successful when cognitive and emotional functioning is similar between members. Aligned levels of functioning also reduce dropout rates and can ensure the needs of group members are adequately addressed (6,10, 13).

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Beginning and Middle Phases of Group Development

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Beginning and Middle Phases of Group Development

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When evaluating the evolution of therapeutic group work through Tuckman's stages, during norming, some group members amongst people experiencing depression assert their dominance, particularly towards the facilitator (10). Facilitators can address assertive speakers in a manner that fosters safety and security for everyone, which promotes early group cohesion while also creating the appropriate environment to integrate collaborative goal setting (10,13).

Storming is represented by this population when cohesion levels off or devolves, and individuals compete with one another for attention.  As tensions arise group members begin to move away from their initial feelings of finding likeness in other group members to needing to differentiate their problems as unique (10). Facilitators can use this stage as an opportunity to incorporate and model more assertive responses to encourage the group to move beyond introductory pleasantries while being mindful that some members of this population will suffer overwhelm when they observe feelings in others they have been suppressing (10).

Performing is demonstrated by this population when members increase their capacity to see themselves in one another and learn from others' experiences (10). Commonly an emotional leader will emerge within the group, a person who models genuine engagement with self-examination. The emotional leader can be a valuable member of the group; however, facilitators must refrain from preferential engagement with the emotional leader, which can lead to resentment within the group (10).

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Group work helps people experiencing depression achieve therapeutic goals that they might struggle to reach during individual therapy (3). Therapeutic groups provide social support, and opportunities to emulate role models while also moving forward as a group to help individual members pursue personal change. For people experiencing depression, change requires unlearning negative thought patterns, confronting challenges, and achieving some control over one's emotions. People can benefit from being part of a group that expands on the level of change achievable on one's own (3).

CBT, or psychotherapy group work with people experiencing depression, has the effect of benefitting the group as a whole through the experience and impact of cohesion, collaborative goal setting, and normalization (10,12,13). The group also functions as a venue for experimenting socially, learning from observing and listening to others, and performing as co-therapists (12). When these psychosocial interventions occur alongside proven therapeutic methods, CBT and psychotherapy, while also delivering accurate information about depression, the benefits produce positive short, and long-term outcomes (7, 12).

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When group therapy is ending, it can elicit strong emotions for people experiencing depression. Often these are founded on experiences of abandonment (10). Therefore, it is common for members to spend closing sessions minimizing their experience in the group as a mechanism for protecting their sense of loss (10).

For some, there may be a tendency to glorify the group experience and gloss over the challenging aspect of the experience. Facilitators should foster an authentic reflection on the group process and encourage participants to balance their closing statements and reflect on the various feelings they have experienced (10). Another consideration for facilitators during closing is that they should resist the urge to explore conflict and stoke productive conversation when there is insufficient time to wrap up new conflict. Finally, group endings offer the facilitator an opportunity to model how to internalize the experience on a personal level and how the collective experience will endure beyond the group's conclusion (10).

Having participated in a collective group experience can reduce the likelihood of future depressive episodes because of group therapy's ability to address psychosocial, psychotherapy, and educational support factors; these variables have proven to predict the likelihood of depression symptoms recurring (7,9).

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Working with people experiencing depression in a therapeutic group format offers the opportunity to implement psychotherapy and psychosocial interventions while disseminating accurate information about depression (1,2,12). Group therapy for this population is an affordable and effective method of treatment (5).

This population requires several considerations to improve the likelihood of positive outcomes. Cautious recruitment, suitability for group work, and suitable membership composition are critical for this population. This is a broad target group, and members are best served by working with those at similar levels of functioning. Facilitators should be cognizant of power issues, and trained in either psychotherapy or CBT. Group leaders should also understand how to foster cohesion amongst people with depression while navigating group phases with agility. Understanding the sensitivity of this population to group endings is also essential. With due care, group therapy for people experiencing depression is a successful intervention for many people who experience this common and challenging mental illness.

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(1)  Alldredge, C., & Burlingame, G. (2020). Group psychotherapy for depression. International Journal of Group Psychotherapy, 70(3), 467–474. https://doi.org/10.1080/00207284.2020.1749521

(2)  Barney, L. J., Griffiths, K. M., & Banfield, M. A. (2011). Explicit and implicit information needs of people with depression: a qualitative investigation of problems reported on an online depression support forum. BMC Psychiatry, 11(1). https://doi.org/10.1186/1471-244x-11-88

(3)  Forsyth, D. R. (2021). Social influence theory and research: Implications for group psychotherapy. In C. D. Parks & G. A. Tasca (Eds.), The Psychology of Groups: The Intersection of Social Psychology and Psychotherapy Research (pp. 87–104). American Psychological Association. http://www.jstor.org/stable/j.ctv1chrwgm.9

(4)  Larson, G. (2008). Anti-oppressive practice in mental health.
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(5)  Lorentzen, S., & Ruud, T. (2013). Group therapy in public mental health services: approaches, patients and group therapists. Journal of Psychiatric and Mental Health Nursing, 21(3), 219–225. https://doi.org/10.1111/jpm.12072

(6)  Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299–2312. https://doi.org/10.1016/s0140-6736(18)31948-2

(7)  McDermut, W., Miller, I. W., & Brown, R. A. (2001). The efficacy of group psychotherapy for depression: A meta-analysis and review of the empirical research. Clinical Psychology: Science and Practice, 8(1), 98–116. https://doi.org/10.1093/clipsy.8.1.98
(8)  Novotney, A. (2018, April). Keys to great group therapy. American Psychological Association. https://www.apa.org/monitor/2019/04/group-therapy
(9)  Sundquist, J., Palmér, K., Memon, A. A., Wang, X., Johansson, L. M., & Sundquist, K. (2018). Long-term improvements after mindfulness-based group therapy of depression, anxiety and stress and adjustment disorders: A randomized controlled trial. Early Intervention in Psychiatry, 13(4), 943–952. https://doi.org/10.1111/eip.12715

(10)Tasca, G. A., Mikail, S. F., & PhD, P. H. L. (2020). Group psychodynamic-interpersonal psychotherapy (1st ed.) [E-book]. American Psychological Association.

(11)Tenenbaum, S., & Singer, K. (2018). Borders of belonging: challenges in access to anti-oppressive mental health care for Indigenous Latinx gender-fluid border-youth. AlterNative: An International Journal of Indigenous Peoples, 14(3), 245–250. https://doi.org/10.1177/1177180118785383

(12)Thimm, J. C., & Antonsen, L. (2014). Effectiveness of cognitive behavioral group therapy for depression in routine practice. BMC Psychiatry, 14(1). https://doi.org/10.1186/s12888-014-0292-x

(13) Walter, I. R., PhD. (2019, November 9). How to establish a therapeutic culture in group Therapy. Family Therapy Basics. https://familytherapybasics.com/blog/2017/9/20/how-to-establish-a-therapeutic-culture-in-group-therapy