Online therapeutic groups: integrative literature review (2012-2022)Abstract
This study presents an integrative literature review on online, synchronous, and hybrid therapeutic groups. The search for publications was conducted in the PsycInfo, PubMed, Embase, Scopus, Web of Science, and Virtual Health Library databases, covering the period from 2012 to 2022. After applying inclusion and exclusion criteria, 34 articles were analyzed (an average of 3.4 articles per year), organized into seven categories: (1) concepts and objectives of group processes; (2) theoretical foundations, instruments, and techniques; (3) target population and group classification; (4) specificities of group work; (5) platforms and communication modalities; (6) therapists; and (7) main outcomes of the interventions. The findings highlight the diversity of approaches in understanding, grounding, and developing online group therapies. These care strategies have shown promise, particularly when in-person sessions are unfeasible. Future research incorporating asynchronous communication in these therapies may expand the reported findings.
Keywords:
Clinical Psychology; Internet-based Intervention; Mental Health Teletherapy; Pandemics
Resumo
Este estudo apresenta uma revisão integrativa da literatura sobre grupos terapêuticos on-line, síncronos e híbridos. A busca por publicações foi realizada nas bases de dados PsycInfo, PubMed, Embase, Scopus, Web of Science e Biblioteca Virtual em Saúde, considerando o período de 2012 a 2022. Após a aplicação dos critérios de inclusão e exclusão, 34 artigos foram analisados (média de 3,4 artigos/ano), organizados em sete categorias: (1) conceitos e objetivos dos processos grupais; (2) bases teóricas, instrumentos e técnicas; (3) público atendido e classificação dos grupos; (4) especificidades do trabalho grupal; (5) plataformas e modalidades de comunicação; (6) terapeutas; e (7) principais resultados das intervenções. Os achados evidenciam a diversidade de enfoques na compreensão, fundamentação e desenvolvimento de terapias grupais on-line. Essas estratégias de atendimento têm se mostrado promissoras, sobretudo quando as presenciais são inviáveis. Pesquisas futuras que incluam o uso de comunicação assíncrona nessas terapias poderão ampliar os achados reportados.
Palavras-chave:
psicologia clínica; intervenção baseada na internet; telessaúde mental; pandemias
Resumen
Este estudio presenta una revisión integradora de la literatura sobre grupos terapéuticos en línea, síncronos e híbridos. La búsqueda de publicaciones se realizó en PsycInfo, PubMed, Embase, Scopus, Web of Science y Biblioteca Virtual en Salud, considerando el período de 2012 a 2022. Tras aplicar los criterios de inclusión y exclusión, se analizaron 34 artículos (promedio de 3,4 artículos por año), organizados en siete categorías: (1) conceptos y objetivos de los procesos grupales; (2) bases teóricas, instrumentos y técnicas; (3) público atendido y clasificación de los grupos; (4) particularidades del trabajo grupal; (5) plataformas y modalidades de comunicación; (6) terapeutas; y (7) principales resultados de las intervenciones. Los hallazgos destacan la diversidad de enfoques para comprender, fundamentar y desarrollar terapias grupales en línea. Estas estrategias han demostrado ser prometedoras, especialmente cuando la atención presencial no es viable. Investigaciones futuras que incluyan el uso de comunicación asincrónica en estas terapias podrán ampliar los hallazgos reportados.
Palabras clave:
Psicología Clínica; Intervención basada en Internet; Teleterapia de Salud Mental; Pandemias
Introduction
There have been indicators of experiences with online groups for over 28 years, with developments continuing to the present day (Donnamaria & Terzis, 2015; Weinberg, 2001, 2020a, 2020b, 2021). In this trajectory, Weinberg (2020) - also considered one of the pioneers of the subject - managed to assert, for instance, that the dynamics of groups in this modality seem similar to those of in-person groups. Furthermore, they may be more accessible to individuals, as they can overcome practical restrictions such as issues of urban mobility and distance, thereby facilitating participants’ continuity in the group process.
However, to discuss group therapy as a method, it is necessary to consider the complexity and diversity of classifications and objectives of groups. Proceeding from this understanding, this study adopted the concept of groups with therapeutic purposes to guide the extraction and discussion of the analyzed data. Fundamentally, this nomenclature encompasses processes that range from developing healthier behaviors, self-awareness, learning in interpersonal relationships, to even engaging with the group as a whole (Santeiro et al., 2021a).
According to Stephanie Pappas (2023), in an article published on the American Psychological Association (APA) website, group therapy is equally effective as individual therapy for various symptoms and conditions, and in many cases, it is more efficient. This occurs due to the reduction of stigma and the sense of solidarity that participants experience when in a group. Regarding online groups, the author highlights the need for more research on the best ways to promote cohesion and enhance therapeutic efficacy in the virtual environment.
Online psychological treatment can be employed in two ways: in the synchronous model, with immediate and shared communication in real time - it can be done through videoconferencing or phone calls, for example. Moreover in the asynchronous format, in which communication between therapist and patient does not occur in real time, as is the case with the use of emails (Siegmund et al., 2015).
Especially after the Covid-19 pandemic, there has been an increase in demand and provision of online psychological services. However, psychotherapies and group interventions have not enjoyed similar attention, for instance, when compared to online individual psychotherapies (Santeiro et al., 2021b). When the literature emphasizes online groups, there is a focus on mutual support groups on social networks, those focused on information exchange and emotional support (Lo et al., 2022). Thus, discussions about online therapeutic groups, with real-time video interactions, for instance, are still in their early stages, and the reviews we found do not present a broader view of what has been practiced and researched in this field (Banbury et al., 2018; Da Silva et al., 2022).
In a systematic literature review that collected publications from 2000 to 2016 on the use of videoconferencing groups to provide social support and/or education in the home environment, it was found that groups in this format are viable and acceptable (Banbury et al., 2018). Similarly, Da Silva et al. (2022) described interventions in synchronous online groups aimed at promoting mental health and preventing mental illnesses in university students; the study yielded satisfactory results and underscored the importance of more research in this field. Although videoconferencing was used as an inclusion criterion in both studies, they do not focus on therapeutic group processes for different audiences.
In this context, we concur with the study by Stefana et al. (2023), which highlights the relevance of reviewing articles that include clinical cases or vignettes. These elements allow for a more comprehensive understanding of certain therapeutic processes, playing a crucial role in bridging the gap between research and clinical practice. In light of this perspective, the overarching objective of the present study was to present an overview of how national and international literature has developed online therapeutic groups conducted in synchronous and hybrid modalities. More specifically, the following variables were investigated: concept and objectives of group processes; theoretical bases; instruments and techniques; target audience and group classification; specific aspects of group work; platforms and communication modalities; group process facilitators; and main therapy outcomes.
Method
This is an integrative literature review, a methodological approach that involves a comprehensive synthesis of various published studies on a specific phenomenon, aiming to contribute to discussions on previous research methods, findings, and future perspectives. To achieve this, the following steps were adopted: 1. identification of the theme and research problem; 2. definition of inclusion and exclusion criteria; 3. categorization of studies; 4. assessment of the sample included in the review; 5. analysis of results; 6. presentation of the review/knowledge synthesis (Mendes et al., 2008).
The searches were conducted with the aim of addressing the guiding question: “How were online therapeutic groups developed, and how were these processes depicted in the specialized literature from 2012 to 2022?” For this purpose, the following databases were consulted as sources of information: PsycInfo, PubMed, Embase, Scopus, Web of Science, Biblioteca Virtual em Saúde (BVS, Virtual Health Library), Literatura Latino-americana e do Caribe em Ciências da Saúde (LILACS, Latin American and Caribbean Health Sciences Literature), and Index Psi.
The adopted keywords were: “group psychotherapy,” “group therapy,” and “online groups,” as provided by the databases, combined with the boolean operator AND, followed by “internet-based interventions” and “remote health services.” The article search took place during the second half of 2022, with the assistance of an experienced librarian in literature reviews.
The inclusion criteria for articles were: (1) articles presenting research reports or experiences related to online therapeutic groups conducted in synchronous and hybrid modalities; (2) written in Portuguese, English, or Spanish; (3) published between 2012 and 2022; (4) available in full. The exclusion criteria were: (1) theoretical studies and/or literature reviews; (2) therapeutic groups with exclusively asynchronous communication; (3) in-person therapeutic groups using online resources only as a supplementary clinical support strategy.
The article screening process involved reading the titles, followed by abstracts, and then a full reading of those that met the inclusion criteria. After these steps, the information was organized in Microsoft Excel® spreadsheets according to specific objectives. As most cases involved categorizing data based on information provided by the authors themselves and/or available in the documents (which were more objective), data entry into the spreadsheets was performed by the first author. However, for concepts of group and (psycho) therapy objectives that required subjective assessments, a double review process was conducted: by an independent judge, who had a Bachelor in Psychology and undergoing a master’s, with expertise in systematic literature reviews; and through supplementary discussions about methodological decisions and the results within the authors’ Research Group focused on group clinical investigations.
In the initial search, 13,853 articles were found. After excluding duplicate texts, there were 12,659 potential references for analysis. Among these, after applying inclusion and exclusion criteria, 34 studies became part of the corpus of the present review (Figure 1). The analysis of these results was performed quantitatively. However, qualitative discussions were incorporated based on theoretical and practical knowledge described in the publications, as well as other relevant literature on the topic. This process included identifying gaps in the field, with the aim of highlighting key contributions, conclusions, and practical implications.
Results and discussion
Prior to presenting the results, for the purpose of contextualizing the found production, we will provide the annual average of articles found, their geographic distribution by continent based on the country of origin declared by the authors, and the types of studies found. Thus, an average of 3.4 articles per year was observed. The lowest frequency found was 1 article in 2015 and 2019, while the highest was 15 studies in 2021. This evolution of production can be better visualized in Figure 2, where a growing trend can be observed shortly after the onset of the Covid-19 pandemic. Some of the investigated groups emerged precisely in response to the health crisis situation and the authors began to investigate them, considering pandemic as a relevant and fundamental aspect (Biancalani et al., 2021; Jelena & Tihana, 2020; Sola et al., 2021; Vivenzio et al., 2022).
Regarding the countries of origin of the analyzed productions, studies were observed from all five continents: Europe (n = 14), Americas (n = 10), Asia (n = 4), Oceania (n = 5), and Africa (n = 1). Among the 34 analyzed articles, 27 were empirical studies and four were experience reports. Three studies, not explicitly indicated by the authors, were classified as illustrated theoretical papers (Ferreira, 2021; Lo et al., 2022; Santeiro et al., 2021b). One of these articles, although labeled by the journal as a narrative review, was referred to by the authors as theoretical reflection and was included in the sample for presenting a clinical section of a group process (Santeiro et al., 2021b).
Among the empirical studies, there are two articles that, despite having different objectives, share the same clinical segment (Brouzos et al., 2021a; Brouzos et al., 2021b). Additionally, it is noteworthy that none of the empirical studies originated from Latin America, whereas three out of the four experience reports were from Brazil (Meneghel et al., 2022; Sola et al., 2021; Vivenzio et al., 2022). In these cases, the group’s implementation itself served as a strategy to cope with emotional issues related to the Covid-19 pandemic.
To continue with the delineation of the scenario aimed at in this study, the following section will present the seven categories created to address the guiding question, accompanied by examples of articles retrieved for each category.
Concepts and objectives of group processes
Based on the authors’ own statements, concepts and objectives of the studied groups were analyzed. As a result, different terminologies were found to refer to online groups, such as Online Group Therapy (Jelena & Tihana, 2020), Online Therapeutic Group (Sola et al., 2021), Online Psychotherapy (Ferreira, 2021), and Internet-Based Therapy (Wajda et al., 2022). The objectives of the group interventions that presented similar concepts included deepening self-awareness, improving interpersonal relationships, providing relief from psychological suffering, allowing the expression of distress, offering support and emotional treatment, and promoting greater awareness of certain behaviors.
There were also studies that defined groups as Operative (Santeiro et al., 2021b), Multifamily (Lo et al., 2022), Multivision (Parrello et al., 2021), and Intervention Group (Meneghel et al., 2022). In these cases, the authors based their approach on the idea of the group as an environment where objectives could be achieved, such as promoting health, strengthening the social support network, facilitating dialogue about feelings and anxieties, and providing learning opportunities. Although designated as such, these studied groups were also considered by their authors as devices suited for therapeutic processes.
In this sense, the analysis of the productions highlighted that a concept stated in a certain study determined the objectives aimed at in the group processes and vice versa. The objectives were closely related to the theoretical bias adopted by the authors. Thus, this characteristic signifies a qualitatively interesting aspect of the analyzed production, as it demonstrates theoretical-methodological coherence, something desirable to exist when manifested in publications that are strictly scientific in nature, as considered in this article.
Additionally, it was possible to observe two coexisting trends when conceptualizations of group interventions were at play. On one hand, there is a trend that comprehends groups within a more established scope of the term, linking them to the idea of (psycho)therapeutic treatments. On the other one, the second trend corresponds to more flexible understandings of ways to propose and be in a group, closer to the idea of (psycho)therapeutic interventions, not necessarily with treatment purposes, but also with (psycho)therapeutic aims due to being linked to notions of health promotion.
Theoretical foundations, instruments, and techniques
The theoretical foundations that underpinned the productions were six, as declared by the authors, and presented in descending order of frequency: Cognitive Behavioral Therapy (CBT) (N=13), Cognitivism (N=3), Psychoanalysis/Psychodynamic (N=3), Positive Psychology (N=2), Psychodrama (N=2), and Humanism (N=1). However, in ten studies, there was no specification of their theoretical foundations, even after the process of analytical reading had been consolidated.
It is worth noting that most of the analyzed articles used CBT as their theoretical and technical basis. This approach has been widely used for internet-based interventions, both synchronous and asynchronous, individual and group. The Cognitive Behavioral Therapy Group (CBT-G) follows the original structure of CBT: the groups are structured, with a predefined time, and participants share common goals, creating a sense of belonging. In this context, interventions need to address the following questions: “Why? For whom?” In the case of online CBT-G, it is crucial to consider both these technical aspects and specific aspects of the group process. The balance between homogeneity and heterogeneity becomes even more crucial, as the group may include people from various locations and different cultures (Neufeld & Szupzynski, 2022).
Regarding the instruments, 129 were cited, regardless of whether they were empirical studies, experience reports, or illustrated theoretical studies. They were characterized as Scales (N=55), Questionnaires (N=32), Interviews (N=8), Inventories (N=7), Written materials (N=7), Audiovisual resources (N=6), Forms (N=5), and finally, Tests (N=2). Additionally, seven instruments were identified as others, as they did not fit into the categories mentioned earlier. For example, a final assessment form was applied through Google Forms®, as well as a protocol for assessing the group process, where the name was not specified (Vivenzio et al., 2022). There was also a subjective assessment of therapeutic group factors, which was also described by the authors as a process aimed at assessing the subjective importance of group therapeutic factors, such as catharsis, hope, universality, interpersonal learning, cohesion, altruism, among others (Ellett et al., 2022).
Although these instruments did not fit into the previously mentioned categories, they contain indicators of qualitative methodological approaches. These approaches aimed, for example, to gather feedback on the experience of participating in group therapy, as well as to better understand the feelings and perceptions of the participants. An example of this is the following questions used in the study by Ellett et al. (2022): (1) How would you describe your experience participating in the online group? (2) What feelings arose from being part of the group?
Furthermore, the use of written materials and audiovisual resources was observed. Some examples were the literary story Come see the sunset by Lygia Fagundes Telles (Santeiro et al., 2021b), PowerPoint files for psychoeducational purposes (Nesset et al., 2022), meditation or relaxation music to help members relax and transition from daily life to the group environment (a stage referred to by the authors as optional) (Lu et al., 2022), and videos aimed at guiding participants on how to use the video platform and providing instructions for checking Internet connection (Lippke et al., 2021).
Among the most reported instruments in the articles, the Depression, Anxiety, and Stress Scale (DASS-21) (N=7) stood out, followed by the Client Satisfaction Questionnaire (CSQ-8) (N=4). In general, most instruments were related to mental health conditions or the degree of satisfaction with the interventions offered. Specifically regarding group processes, the following instruments can be mentioned: the validated California Psychotherapy Alliance for Group Scale, which aimed to measure group cohesion (Sansom-Daly et al., 2021), the California Psychotherapy Alliance Scale Group (CALPAS-G) used to assess participants’ perceptions of therapeutic alliance during and after the intervention (Wakefield et al., 2015), and a focus group to explore whether group participants perceived any changes in themselves, their family members, or their family relationships (Lo et al., 2022).
An important issue regarding the use of these instruments was highlighted in the analyses: their applicability in online environments. Brazilian psychology professionals, for example, are recommended to use only instruments supported by studies with evidence of validity for computer-mediated or online application (Conselho Federal de Psicologia, 2020).
In any case, the use of technology with groups opens up a range of technological and creative resources that can be explored during, complementary to, or after therapy sessions. There is a study, for example, that defines the creation of stories as the main group activity, as it allows giving meaning to the world and identifying coping and resilience strategies. Based on this understanding, the authors adopted the 6-Part Story Method (also known as 6PSM), using Google Paint® on Microsoft Teams®, collectively. This method is a dramatic therapeutic technique that allows created stories to be incorporated by both the storyteller and the listener. In this case, the story allowed for reflection on loneliness, friendship, and the restrictions caused by Covid-19 (Bourne et al., 2022).
In this sense, the techniques found are also closely linked to their theoretical foundations. In the text Walking with online Psychodrama (Ferreira, 2021) possibilities of techniques for online psychodramatic sessions are mentioned, such as unspecific verbal warming-up, unspecific physical warming-up, specific warming-up, videos, sculptures, and dramatic games. The author points out, for example, that the mirroring technique commonly used in in-person sessions for the patient to see their own sculpture is not necessary to apply in the context of online groups, as each member can see themselves on the screen; therefore, self-observation occurs simultaneously with each moment of audiovisual transmission. Another article, also following the psychodramatic perspective, cites techniques such as role reversal, doubling, and soliloquy (Biancalani et al., 2021). In another study with a distinct theoreticalmethodological approach, the authors not only state that they adopt positive psychology techniques but also report adopting an approach known as “shotgun,” where participants learn various distinct positive psychology techniques (Brouzos et al., 2021a).
Other reported strategies include dialogical techniques, listening activities, musical improvisation and composition, as well as other playful activities (Vivenzio et al., 2022); stretching exercises to invigorate the group; multisensory resources available on the internet, such as cartoons; and the use of the breakout room function to facilitate information exchange between participants (Lo et al., 2022). Specifically regarding physical activities, there is a gap in the literature about how the mediation, development, and adherence of group members to such practices occur, in the sense that these authors do not provide specific details in their studies regarding the online management of these activities.
The theoretical foundations, instruments, and techniques described provide an overview of how group processes were portrayed in the analyzed articles. Specifically, it was noted that this endeavor is permeated by methodological distinctions within the unique paradigms of each approach and intervention, considering their contexts and specificities. For instance, one study reported that the general structure of sessions consisted of the three classic phases of psychodrama: warming up, action, and sharing. These techniques were adapted for the online modality (Biancalani et al., 2021). Another study detailed, in stages, how the proposal should be developed, including from the introduction of the leaders to the group’s closure through reflections on shared experiences (Lu et al., 2022).
A third study shared the same characteristic by reporting the group’s organization divided into phases: 1) welcoming; 2) warming up; 3) technique;
4) processing; and 5) closing and evaluation of sessions by participants. Although these stages were not explicitly detailed, the authors, in the results and discussions, mention reports about the sessions and cite, for example, the need to guide participants regarding technological issues (Vivenzio et al., 2022). Despite the somewhat similar ways in which the groups were conducted regarding technological guidance, explanation of objectives, coordinators, and participants, there are distinctions from the organization to the structuring and handling of the group itself, demonstrating the diversity of possibilities for action in this scenario.
Target audience and group classification
The adult population was predominant in the studied documents (N= 32). However, two studies neither specified nor provided indicators of any developmental stage (Ferreira, 2021; Lu et al., 2022). In this regard, since we understand that each group has its own particularities, the classification of group work was also added as an item to the data table for this review.
Types of groups were classified as homogeneous or heterogeneous, open, closed, semi-open, or semi-closed. The first two terms relate to the group’s composition in terms of individual characteristics of its members. A homogeneous group is made up of individuals who share similar characteristics, while a heterogeneous group consists of people with distinct characteristics. The terms “open,” “closed,” “semiopen,” and “semi-closed” relate to the degree of access people have to the group. A group is considered open when it allows new members to join at any time, closed when it does not admit new members after its formation, while semi-open or semi-closed groups are more flexible, allowing the new members to join these groups at certain times (Santeiro et al., 2021a).
In relation to the analyzed studies, it is noteworthy that only one article specified that the group was composed in a homogeneous manner (Sola et al., 2021). In other studies, when authors describe participants’ characteristics, there are indicators of some group classification, although they are not explicitly mentioned in the body of the text. For example, the study entitled Online therapeutic group: care device for university students’ mental health in times of pandemic (Vivenzio et al., 2022) included university students in its sample, suggesting that the group was formed in a homogeneous manner. The participants of other studies also presented this characteristic (Lleras de Frutos et al., 2020; Nesset et al., 2022).
One possible hypothesis, among many others, is that the lack of detailed information on these data may have occurred due to the emphasis on cognitivebehavioral theories adopted in most articles. As these theories already advocate for the homogeneity of group composition and objectives as an important technical aspect, aiming to promote group therapeutic factors and the development of participants’ sense of belonging (Neufeld & Szupzynski, 2022), it is possible that these group classifications, which can vary based on theoretical-methodological approach, may have been omitted by the authors. On the other hand, even studies that reported other theoretical foundations did not explicitly mention these data. This scenario therefore suggests a broader overview regarding the lack of this information regarding group processes and highlights a greater need for attention to this information in scientific research.
It is also worth noting that, in the analyzed studies, there was no mention of how an individual can join a group. While authors’ reports on group sessions might offer some indications of whether the group in question is open, closed, semi-open, or semi-closed, it is not possible to precisely describe these categories based solely on these indicators. Once again, it is crucial that future research involving group processes include a description of the classifications of groups used, given the relevance and specificity of these data for the field of study in question.
Specificities of group work
Regarding the reports of experience and theoretical studies analyzed, the number of members in the groups ranged from 2 to 13 participants, with an average of 9.5 members per group. It is important to note that one study was excluded from this analysis as it did not provide clear information on this aspect (Lo et al., 2022). In relation to the number of sessions, the average was 13.6 per group. The group with the lowest number of sessions held a total of 8 (Lo et al., 2022), and the largest, 24 (Sola et al., 2021). There was only one study that did not explicitly provide this information, in which the author presented three case studies to illustrate possibilities for engagement in the online environment, each reported based on a specific session. Consequently, it was not possible to determine the entire therapeutic process or the exact number of sessions (Ferreira, 2021). Lastly, the average session duration was 112.5 minutes per group, with the shortest lasting 60 minutes (Sola et al., 2021) and the longest, 180 minutes (Meneghel et al., 2022). It is relevant to mention that three studies did not specify the duration of the sessions (Ferreira, 2021; Jelena & Tihana, 2020; Santeiro et al., 2021).
The included empirical studies presented different characteristics compared to the reports of experience and theoretical studies. Since many of these studies consisted of randomized clinical trials, it was common to have two groups: an intervention group and a control group (for example, Zhang et al., 2021). Additionally, the number of sessions and the duration of groups varied, as evidenced in the study entitled Remote group therapies for cognitive health in schizophrenia-spectrum disorders: feasible acceptable, engaging, which aimed to assess the feasibility of remote group therapy for patients with Schizophrenia Spectrum Disorders (SSDs). In this study, two groups were established: the ActionBased Cognitive Remediation (ABCR) group, lasting 90 minutes for 14 to 16 sessions, and the Metacognitive Training (MCT) group, lasting 45 to 60 minutes for 10 sessions (Mendelson et al., 2021).
Platforms and communication modalities
Among the examined studies, 29 were conducted synchronously among participants, while three did not clearly indicate the form of communication used
(Lo et al., 2022; Parolin et al., 2021; Zhang et al., 202). Two studies were conducted in a hybrid manner, combining real-time sessions with others that did not require simultaneity (Abedishargh et al., 2021; Schuster et al., 2019).
The studies that did not provide clear information about the communication modality were considered in this review, as they provided useful information about how the interventions were conducted. For example, the study entitled Italia Ti Ascolto [Italy, I am listening]: an app-based group psychological intervention during the Covid-19 pandemic, used an app that offered online chat rooms with specific themes for different audiences. These rooms were led by licensed psychotherapists and were guided by research on the needs of each group. The users could choose rooms, schedules, and therapists when registering in the app (Parolin et al., 2021).
Among the most used video conferencing platforms in different studies, it was observed that Zoom® (N=12) was the most frequent, followed by WebEx® (N=3), Skype® (N=3), proprietary sites or apps (N=3), Microsoft Teams® (N=2), Google Meet® (N=1), Google Hangouts® (N=2), ViTAM® (N=1), and Minddistrict® (N=1). Moreover, the video conferencing platforms used were not specified in five studies (Ferreira, 2021; Lippke, 2021; Lo et al., 2022; Santeiro, 2021b; Zhang, 2021).
Regarding the selection of these platforms, it is important to highlight some considerations that should be carefully weighed for conducting mental health interventions online. First, it is essential to assess the security standards provided by the applications, including access control, encryption for portable devices, and the implementation environment (Bennett et al., 2010). Additionally, psychology professionals have broader practical recommendations provided by the APA regarding the use of telepsychology services. One of these recommendations involves, for example, a careful analysis of potential risks to privacy and patient/ client confidentiality, as well as an ongoing assessment of the suitability and feasibility of the service delivery throughout the entire process (Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013).
Furthermore, some studies mentioned the use of applications like WhatsApp® and WeChat® to enhance communication and mediation with group members (Abedishargh et al., 2021; Lu et al., 2022). It is crucial to emphasize the use of these resources as they can encourage group members’ participation but can also have detrimental effects if used inappropriately, such as informing about absences or fostering discussions on other topics like controversial and personal matters. This can result in effects opposite to what is expected, hindering group cohesion. However, if the choice is made to form groups on WhatsApp® or another app, the literature has suggested establishing clear rules about content sharing, and the professional team should act as a moderating power to avoid problems in the intervention process (Neufeld & Szupzynski, 2022).
Group therapists
The role of group therapists is a fundamental variable in the group process, as their presence can foster the building of trust and hope, as well as the connection of group members with their needs (Santeiro et al., 2021a). The analysis of the sample in this study indicated that the team responsible for the therapeutic groups was predominantly composed of professionals belonging to a single category (N=24), followed by multi-professional teams (N=1), and finally transdisciplinary teams (N=1). In eight studies, it was not possible to identify this characterization.
Regarding the academic background of the professionals involved in the groups, a variety of disciplines were mentioned, ranging from psychology, medicine, nursing, music therapy, and social work. Therapists specialized in different approaches were also observed, such as Cognitive-Behavioral Therapy (Abedishargh et al., 2021) and Psychodrama (Biancalani et al., 2021). This variety reflects the possibilities of theoretical and technical foundations that have been described in the categories discussed earlier. Moreover, the qualifications of professionals working in these fields were equally diverse, ranging from undergraduate students to postgraduate professionals.
Main outcomes of the interventions
According to the findings of the authors of the examined articles, therapeutic groups produced beneficial effects, such as better family relationship and sense of community support (Lo et al., 2022); tension relief, mutual assistance in crisis situations and maintenance of support networks (Sola et al., 2021); sense of group belonging and cohesion and emotional support (Vivenzio et al., 2022). In addition, other findings indicated subjective well-being improvement (Meneghel et al., 2022); increased behaviors self-esteem and significant reductions in levels of depression and social phobia (Wajda et al., 2022); as well stress and anxiety (Lu et al., 2022).
Furthermore, these results can be extremely promising for a better understanding of the online environment. As an illustration, one study examined the effectiveness of Internet-based Cognitive-Behavioral Therapy in reducing the body mass index of obese individuals by modifying excessive eating thoughts and behaviors (Abedishargh et al., 2021). The authors highlighted that these individuals fear or feel shame during in-person sessions due to concerns about potential negative judgments related to their physical appearance. Consequently, these patients can benefit from online psychological interventions.
In this perspective, the following question arises: is there a recommended profile and another not recommended for online group psychotherapeutic sessions? Besides this inquiry, it is relevant to question the applicability of contraindications established for in-person group psychotherapy to the online modality, as well as to analyze in detail which therapeutic outcomes can be potentially achieved in this context.
In addition to the aforementioned results, other studies provided indicators of feasibility and acceptability among the participants (Biancalani et al., 2021; Bourne et al., 2022; Ellett et al., 2022; Jelena & Tihana, 2020; Mendelson et al., 2021; Meneghel et al., 2022; Santeiro et al.; 2021b; Schuster et al., 2019; Sola et al., 2021; Vivenzio et al., 2022). The question of how much people would participate and engage in an online group emerged in one of the writings. The authors express concern when proposing a group in this format, particularly regarding the participants’ trust in sharing feelings and painful experiences through social media (Meneghel et al., 2022).
Furthermore, the level of adherence is reported in various ways in the experience reports: (a) through voluntary participation, the establishment, and maintenance of spatial and temporal conditions during group sessions (Santeiro et al.; 2021b); (b) by a favorable reception of the idea of developing an online group, resulting in a similar average participation rate to that observed in face-to-face sessions (approximately onethird of the sessions were attended by group members) (Jelena & Tihana, 2020); (c) through group cohesion, attendance, and active participation in conversations (Sola et al., 2021); and (d) by how participants showed engagement in the group, paying attention to other participants’ communication, although not always expressing themselves verbally (Vivenzio et al., 2022).
There were also empirical studies that provided detailed information on adherence objectively, pointing out that twenty-one participants (75%) completed the therapy, in contrast to only seven (25%) dropouts (Mendelson et al., 2021). In this case, participants also demonstrated acceptability and feasibility of the group proposal; the majority did not mind the physical distance and would recommend the group process to others, a result similar to face-to-face group therapies.
Another study mentioned that 17 out of 21 participants (81%) completed one of the three therapy groups conducted consecutively (Ellett et al., 2022). Yet another research reported that participants appreciated the online nature of the group due to its convenience and the opportunity to meet people with similar experiences and share coping strategies (Bourne et al., 2022). Finally, one study had one of its patients dropping out, resulting in a completion rate of 96% (26/27) (Schuster et al., 2019). Thus, the main findings from the analyzed studies indicated that participant acceptability and adherence can provide crucial indicators to be considered in online group interventions. These findings may also be taken into account in future scientific articles aiming to outline the panorama of the investigated area.
Final considerations
This review provided an overview of how online therapeutic groups (synchronous and hybrid) have been developed in national and international literature, through the analysis of articles available in the several scientific reference databases. The analyzed studies revealed a diversity of approaches in working with online groups. Different terminologies and objectives were observed in therapeutic processes, indicating the existence of distinct practices. The presented scenario highlights the promise of this mode of therapy, especially in situations where in-person sessions are not feasible due to accessibility challenges.
It is worth noting some limitations of this review, such as not including certain existing databases and the possibility that some studies might have been excluded for not fitting the established criteria or for not being published between 2012 and 2022. Additionally, the inclusion of publications solely in English, Portuguese, or Spanish limits the outcomes, although it is academically acknowledged that English is the predominant language. Thus, broadening the sources of information, the temporal scope, and the languages could be relevant approaches to locate other scientific productions, providing a more comprehensive overview of the investigated themes. Moreover, the seven analytical categories explored in this study do not exhaust the range of possibilities for discussing topics intertwined with the guiding question. For instance, issues related to therapeutic alliance and group cohesion require further and ongoing investigations.
Future studies could consider the asynchronous communication mode to expand the presented findings. Moreover, it is paramount that more experience reports are shared with the public, in order to further disseminate the psychological work with online groups that many professionals are already conducting. This aspect needs to be more valued and encouraged, as practical experience is an essential complement to research results.
DATA AVAILABILITY STATEMENT
The research data is not available.
Acknowledgments:
This study was conducted within the scope of the Graduate Program in Psychology (PPGP) at the Federal University of Triângulo Mineiro (UFTM) and received funding from the Minas Gerais State Research Support Foundation (FAPEMIG). We extend our gratitude to Professor Sabrina Martins Barroso for her contributions during the initial planning of the study and to Psychologist Matheus Barra e Silva for his assistance in data collection.
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