Learning about group dynamics is essential for physicians as they participate in interdisciplinary teams [1] and serve in leadership roles in clinics, medical school departments, and hospital administrations. This work is important for psychiatrists, in particular, who can use group dynamics concepts and skills in clinically related small groups (e.g., inpatient treatment teams, consultation groups, Assertive Community Treatment) and who can practice group psychotherapy [2, 3]. By acquiring a group-level approach, psychiatrists are also better positioned to assess the impact of shifts in their practice landscape, currently relevant as psychiatrists increasingly move from stand-alone private practices to larger health care systems and inter-professional collaboration.

Many psychiatry programs offer “process groups” which help trainees learn how to observe, understand, and harness group dynamics through experiential learning, a broadly effective teaching method in health care [4] and a tradition of group training [5]. At present, there are no recently published guidelines on process group best practices during psychiatry training. This paper fills that gap by describing core features and outlining the authors’ recommendations to program directors, process group leaders, and trainees. Process groups offer opportunities for experiential learning in multiple areas including self-awareness, interpersonal skills, and small group dynamics [6,7,8]. At the same time, process groups are challenging and complex, requiring careful pre-implementation planning and ongoing consultation.

As relevant empirical studies are limited, these recommendations come from a review of clinical education literature in psychiatry, psychology, and social work over the past 50 years, from the authors’ prior experiences with process groups in multiple roles (member, leader, director of psychotherapy training, associate program director) and their work in co-creating group psychotherapy and group dynamics curricula.

Process Groups During Psychiatric Training: Background, Core Features, Label Ambiguity, and Potential Benefits

Psychiatry training programs traditionally included experientially focused groups for residents [8] in varied formats including encounter groups, psychodrama groups, T-groups, marathon groups, and psychoanalytic psychotherapy groups [9]. Two separate reports at different historical timepoints suggest roughly half of residency training programs included T-groups [10, 11]. During the COVID-19 pandemic, the authors developed an online cross-residency group dynamics course with didactics and experiential T-group [12] to make the opportunity more broadly available.

Process groups during psychiatry training serve many functions and incorporate features from other traditions of group-based learning including T-groups, group relations, Balint groups, and support groups (Fig. 1). In the 1940s, Kurt Lewin and colleagues developed T-groups at the National Training Laboratory with the goal of leveraging a deeper understanding of group dynamics to foster positive social change [13]. Like T-groups, psychiatry training process groups focus on subjective experience in the moment (the “here and now”) and closely examine interpersonal and group dynamics [6]. Wilfred Bion’s group theory, and the Group Relations tradition which emerged from it, consider the “group as a whole,” in which the contribution of any individual member is “speaking for the group.” Psychiatry training process group leaders use group-as-a-whole interventions to decrease personalization and foster systems thinking [7].

Fig. 1
figure 1

This infographic illustrates how psychiatry residency process groups incorporate features of other groups focused on clinician training

Full size image

In contrast to T-groups and Group Relations, psychiatry training process groups often include emotional support exchanges, as training in psychiatry is both a stressful and an important developmental period of professional identity formation [8]. In addition, psychiatry training process groups may include discussions of difficult clinical cases, similar to Balint groups. However, some activities are not a part of psychiatry training process groups, especially pre-established content such as didactic education, skills training, or mindfulness practices. These activities happen in what might be labeled “content groups,” which do not invest time and space to study and learn from what can emerge in a small group.

Process groups during psychiatric training are complex in their features and in their name; the “process group” label itself is ambiguous. Are residents to “process” their experience of working with psychiatric patients and professional formation? Are they “processing” a sentinel adverse event? Or are they “processing” their experience of each other and the group? As we have described, all of these “processes” might be included. Ambiguity allows skilled and experienced facilitators to assess the capacity of the specific trainee group and respond flexibly with regard to focus (e.g., clinical work, professional formation, emotional support, group as a whole, interpersonal learning, self-awareness).

At the same time, the “process group” label ambiguity is challenging for novice process group leaders, and it can blur the line between education and treatment [8]. Given this, it is vital that program leadership and process group leaders have a clear understanding of the differences between process groups and psychotherapy groups (Table 1). While some trainees may find participation personally helpful, a process group is intended to be an educational endeavor. It is not intended to provide psychotherapy.

Table 1 Comparison between psychotherapy groups and process groups during training in psychiatry
Full size table

Potential process group benefits include increased awareness of how systemic factors influence individual challenges, deepened capacity for observation and reflection of group process, and an experiential understanding of core concepts in group dynamics such as psychological safety, group development, and role differentiation. Additionally, trainees observe senior facilitators demonstrate their approach to group facilitation. They may gain a greater appreciation of the complexity and effort involved in leading groups and teams [14]. They may experience decreased social isolation and increased social connectedness, reducing the likelihood of burnout [15].

Recommendations for Training Program Directors

Implementing process groups during psychiatry training requires thoughtful preparation. Program leadership can reinforce the primary educational mission by scheduling the process group in a time designated for academics, pairing the experientially focused process group with an explicitly didactic component, and developing clearly stated learning objectives [16]. Potential methods to pair didactics with the process group include the process group leader(s) offering brief written process summaries, offering verbally-conveyed micro-didactics with each meeting, or offering review and application sessions after the conclusion of the experientially-focused process group. Alternately, a different faculty member can lead a concurrent didactic seminar.

Learning goals and objectives will vary based on process group membership and can be designated primary and secondary in importance. For example, in larger programs that include process groups for each training year, the intern group can focus primarily on support during professional formation and secondarily on learning more advanced concepts in group dynamics. In these programs, the senior resident process group would instead prioritize interpersonal and group dynamics. In the case of smaller residency programs, it is possible to combine multiple training years, which leads to broader goals to meet the needs of trainees at different developmental stages. The conversation about goals and objectives between program directors and process group leaders can bolster their working relationship, better positioning each colleague to respond to difficulties that might arise from their respective professional role positions.

Carefully selecting and recruiting process group leaders is important. When a skilled and experienced psychiatrist is available, trainees are more likely to perceive psychosocial expertise as part of psychiatric identity. If a skilled, experienced psychiatrist is not available (or has an inherent conflict of interest as a supervisor or leader in the training program), then an experienced, skilled psychologist or social worker is preferable, as an unskilled psychiatrist leader undermines and disrespects the work. When possible, process group co-leadership is optimal in that it creates opportunity for more representation with diverse and non-dominant intersecting identities [12, 17].

Group psychotherapy training is vital and foundational for process group leaders. The Certified Group Psychotherapist credential offered by the American Group Psychotherapy Association is a marker of excellent group psychotherapy training [18]. However, this credential is a starting point, because process groups manifest a complex educational mission with values that are different from those found in group psychotherapy (Table 1). Having a clear arrangement of how the process group leaders will be compensated for their time and effort is also critical. This arrangement can include a combination of financial support, support for continued training in group work, and other resources (e.g., adjunct academic appointment, access to academic/library/digital resources, involvement in continuing education).

Problems in the process group usually indicate problems also occurring outside it, not only within [8]. Regardless, there are also ethical considerations to address, pitfalls to avoid, and difficulties to manage. Psychiatry trainees are frequently in contact outside the group experience as colleagues on the wards or in the classroom, friends, or romantic partners. Interpersonal conflict or self-disclosure in the process group may adversely affect work and personal relationships [19]. Even when participation is explicitly voluntary, there may be unspoken social consequences of not participating. In addition, the process group may be a more difficult experience for members with less privilege with regard to social identity, in part because it can be taxing to repeatedly give voice to a minority experience. Further, the cultural values which shape process groups can go unacknowledged, and process group leaders may be less experienced in working with group dynamics related to issues such as racism, sexism, and other forms of oppression at multiple levels (intrapsychic, interpersonal, group as a whole, systemic). Given these ever-present systemwide dynamics, after thoughtful consideration, a program may decide to make participation required, expected but not required, or elective. Participation may also vary across the training years (e.g., required for interns with primary focus on support during professional formation, elective for senior residents focused on interpersonal and group dynamics). Finally, there may be other valid individual reasons for a resident to elect non-participation.

After completing the initial planning, we recommend that programs provide trainees with an orientation guide that includes a rationale, learning objectives, and group agreements for participation [19]. Ideally, these guidelines are reviewed with both the program director and the group leader together. At this meeting, the relationship and boundaries between the program director and the process group leaders(s) are explicitly declared with regard to what will be shared with the program director. It is better to be up front about limitations on confidentiality with regard to attendance and the content of conversations (e.g., disclosure about psychiatric symptoms including suicidality).

At the close of the process group, collecting written feedback [16, 19, 20] can help both with quality improvement and with providing a cognitive frame for the group experience by explicitly referring back to the learning objectives. In an optimal arrangement, consultation meetings are available to process group leaders from different training programs to encourage continued professional development and growth, including advancements in equity and social justice in the practice of learning group dynamics.

Recommendations for Process Group Leaders

The first work of leading a process group is developing a solid relationship with the training program director, which includes finding agreement on process group learning objectives, placement in the curriculum, nature of member participation (mandatory vs. elective), form of compensation for the leader(s), and length of group. In addition, process group leaders are tasked with deepening their knowledge, skill, and attitudes in their areas of relative weakness and modifying their approach to group psychotherapy to fit the educational mission of the psychiatry training program.

It is vital that the group leader actively seek out knowledge, develop skills, and foster the attitudes necessary for proficiency in multicultural group facilitation [12, 21,22,23], and to do this, it is necessary to engage in ongoing training related to issues of diversity, equity, and inclusion in groups. Group leaders may opt to self-disclose visible or invisible aspects of their identities to broach the topic [12].

It is important to develop group agreements, which are similar to but distinct from agreements developed for psychotherapy groups. Because trainees in psychiatry, like other physicians, usually have some perfectionism, it is useful to clarify that agreements are guidelines, not rules. While rules must be obeyed or disobeyed, agreements can become the foundation of working relationships. At the same time, it is necessary for participants to hold the intention to abide by the agreements. However, in place of fear or shame driving compliance, falling short of an intention can be used as information about the group experience. This approach works especially well when including a “fallibility agreement” [24], which encourages non-defensiveness by explicitly acknowledging that we do not always follow through on our intentions.

Process groups may be short term (e.g., 1- or 2-day experiences) or longitudinal (e.g., once per week for 6–10 months or throughout residency) [6,7,8, 25]. Most of the literature on process groups has focused on managing the dynamics of small groups; coupled with our own experiences in process groups of varying sizes, we recommend no more than 10 members per group.

During the process group, we recommend leaders keep interventions in the here and now, so as to not imply that sharing past personal experience is the most important contribution. It is also useful to make some interventions at the level of group as a whole [7], which can distinguish the process group from psychotherapy and foster thinking about systems. It can also be useful to collect post-group reflections [12].

Recommendations for Process Group Members

Participating in psychiatry training process groups can facilitate an important shift in perspective and bolster capacity for self-reflection. In didactic seminars, it is possible to learn by focusing attention on the instructor and engaging intellectually with the material presented. In contrast, process groups require shifting attention to one’s own internal experiences (thoughts, feelings, impulses, etc.), as well as one’s experience of the group leader(s) and other members.

We recommend cultivating the attitudes of open-mindedness, curiosity, and playfulness while participating in the group. Treating other group members with respect and courtesy is imperative and includes maintaining confidentiality and minimizing discussion of group material with group members outside of the process group.

Members should be aware that there may be unanticipated impact in disclosing personal information, particularly given that fellow group members are potential lifelong colleagues. We recommend using consistent feelings of psychological safety and cohesion in the group to guide decisions around self-disclosure [19, 20]. Members should be aware that conflicts from the process group may affect working relationships, given the frequency of interactions of group members outside of the group. As much as possible, we recommend staying mindful of one’s areas of relative social privilege and how these impact one’s level of comfort in the process group. We also recommend examining the behavioral norms shaped in the process group, the values that inform these norms, and how these values compare with other cultural values present in the group (e.g., from individual members, the training program, the field of medicine). Although the process group can be a place to seek emotional support, we recommend seeking psychiatric treatment for severe emotional distress, including any safety concerns such as suicidal thoughts. Finally, given these complexities, it ought to be possible to choose to not participate in the process group.

Conclusions

There are no recently published recommendations on implementing process groups for trainees in psychiatry. Further work includes systematically surveying current trends in training programs, empirical study, and incorporating a diversity-conscious lens in all aspects. While we await that further scholarship, we believe that the learning involved in process groups is vitally important. When program directors, group leaders, and member-participants prepare and understand potential opportunities and pitfalls, the chance of successful outcomes is optimized. Process groups are a special aspect of training in psychiatry. Leaders in psychiatric education would do well to nurture and support them.