New horizons in group psychotherapy research and practice from third wave positive psychology: a practice-friendly review

Abstract

Group psychotherapy has been shown to be equivalent to individual therapy for many disorders, including anxiety, depression, grief, eating disorders, and schizophrenia (Burlingame & Strauss, 2021). In addition to effectiveness in reducing symptoms, group offers members a sense of belonging, purpose, hope, altruism, and meaning throughout treatment (Yalom & Leszcz, 2020). These additional outcomes are especially important considering the COVID-19 pandemic and national/international conflicts, given the trauma, disruptions, and losses people have experienced. Applying recent developments in positive psychology to group therapy can enhance treatment. A practice-friendly review examined recent advances in the positive psychology literature, demonstrating how group therapy offers members unique growth opportunities in addition to reducing symptoms. Key findings from studies applying positive psychological constructs to group therapy outcomes are synthesized. Our review sheds light on the relevance of third wave positive psychology to enrich group therapy (Lomas et al., 2021). Specifically, group therapy can facilitate the development of vitalizing psychological virtues, and these can be used to assess treatment outcome: humanity, wisdom, transcendence, courage, temperance, and justice. Interrelatedly, we present support for including attachment theory and mentalization within a positive psychological group framework. Implications are explored for group therapy research, clinical work, and training.

Introduction

Group psychotherapy has been shown to be equivalent to individual modalities for many disorders, including anxiety, depression, grief, eating disorders, and schizophrenia (Burlingame & Strauss, 2021). This is especially important given the intersectional mental health impacts of COVID-19, racial injustice, and healthcare inequality, which have fuelled feelings of isolation, loss, hopelessness, mortality salience, and uncertainty (Marmarosh et al., 2021). Although the literature has demonstrated how group therapy can uniquely benefit people through facilitating belonging, universality, hope, altruism, and meaning (Yalom & Leszcz, 2020), recent research has focused more narrowly on the treatment of specific disorders. Emblematic of psychotherapy research more broadly, empirical studies on group increasingly concentrate on effectively addressing symptom distress. While certainly a central aspect of quality care, this approach neglects notable facets of the human experience and can reduce clients to their symptoms. Countering this trend, McWilliams (2022) argued that it is critical to examine not only symptom change, but also holistic developmental and well-being outcomes - framed as ‘vital signs’ in psychotherapy - such as capacities for forgiveness, gratitude, hope, tolerance of differences, and empathy. These constructs fall under the umbrella of positive psychology, in line with key virtues described by Seligman (1998, 2019).

Considering this gap in the empirical literature, the current practice-friendly review explores the salience and import of positive psychology as a uniquely vitalizing force in group therapy, with the aim of promoting innovation in both research and clinical practice by applying holistic, dialectical, and strengths-based understandings of mental health and human flourishing.

Positive psychology and mental health

The field of positive psychology became a major initiative of Martin Seligman (Seligman & Csikszentmihalyi, 2000) as president of the American Psychological Association. Seligman noted the pivotal post-World War II focus in psychology on psychopathology and the treatment of mental disorders, but noted it was vital to also develop scientific research and interventions focused on catalysing human strengths, optimal functioning, and flourishing. Arguably, numerous other precursors in the second half of the twentieth century also indirectly influenced the emergence of positive psychology, such as an increased emphasis on growth and meaning in humanistic and existential branches of psychology; the multicultural and feminist movements, which challenged and expanded on existing therapy approaches; and increased empirical attention to links between spirituality/religion and health, countering the ways this domain had often been previously dismissed or pathologized in the mental health field.

Virtue, well-being, and flourishing are three key constructs, but also organizing themes, within the vast literature of positive psychology. Virtues are ‘qualities of human character and excellence which enhance the capacity to live well’ (Sandage & Hill, 2001, p. 243). While some clinicians can find the language of ‘virtue’ to be off-putting and imply a kind of rigid moralism, the term has traditionally referred to developmental strengths and capacities that foster effective life functioning when applied wisely in specific contexts (Goodman et al., 2022). In this sense, therapists are regularly working with clients to cultivate and apply certain strengths in ways that fit particular life challenges. There are now large bodies of research examining many virtues, such as forgiveness, compassion, gratitude, and hope, among others (Jankowski et al., 2020).

Well-being and flourishing are overlapping, multi-dimensional constructs with diverse definitions. Positive psychologists often distinguish between hedonic and eudaimonic forms of well-being (Waterman, 2013). Hedonic (or subjective) well-being refers to feelings of enjoyment, happiness, and life satisfaction, while eudaimonic wellbeing can be traced back to Aristotle’s notion of eudaimonia, often translated as ‘flourishing.’ Eudaimonic well-being is more multi-faceted and growth-oriented, including a sense of meaning and purpose in life, healthy relationships, and contributions to the wider community. The relational orientation of eudaimonic well-being might be of particular interest to group therapists who are typically trying to help clients grow in relational capacities. While these differences between hedonic and eudaimonic well-being may be useful to researchers, more clinical data is needed to determine the extent to which clients can - and find it useful to - distinguish between well-being facets. There is some evidence of distinctions between emotional and social forms of well-being among clients (Jankowski et al., 2022), suggesting important clinical research questions emerging from the integration of positive psychology and mental health.

So far, the positive psychology movement has led to the development of specific positive psychotherapies (e.g., Fava, 2016; Seligman, 2006) and group interventions to foster specific virtues (for reviews, see Jankowski et al., 2020; Captari et al., in press). However, positive psychology has had a more limited impact on routine mental healthcare, probably due to several factors. At least initially, clinicians typically need to focus on clients’ mental health distress, and it might be unclear how to integrate positive psychology with sensitivity and effectiveness in responding to clients’ suffering. Furthermore, it is unlikely that most therapists would set aside other evidenced-based approaches in favour of adopting one of the new positive psychotherapies. Thus, it is significant that McWilliams (2022), a leading figure in contemporary psychoanalytic psychotherapy, has articulated vital signs of progress in treatment. A master clinician and scholar, McWilliams suggests that effective treatment - across theoretical orientations and modalities - should lead to positive developmental and relational outcomes beyond just symptom alleviation. This view likely resonates with many clinicians who are dissatisfied with the medical model’s reductionistic focus on pathology alone. There is some evidence clients may envision more holistic goals for treatment than simply symptom alleviation (Zimmerman et al., 2006), although it is interesting to note the limited research available on clients’ desired outcomes.

The World Health Organization (WHO; 2018) defines mental health as ‘a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’ (para. 1). This eudaimonic-like definition of positive mental health fits with McWilliams’ (2022) emphasis on positive developmental capacities, and the communal orientation goes beyond Western individualism to be more inclusive of collectivistic cultures. However, it is not necessary to choose between either a symptom alleviation or well-being focus in treatment. Dual factor approaches to mental health attend to both symptoms and well-being as relatively distinct dimensions that can be moderately correlated, but not synonymous. For example, a client might show low symptom distress but also low well-being, perhaps due to overuse of less adaptive and de-vitalizing psychological defenses. Or a client might display heightened distress but moderate well-being due to strengths in meaning-making and relational support. Clinicians and researchers can utilize a dual factor framework to assess for and attend to both symptoms (or suffering) and these kinds of vital signs of well-being and positive growth toward flourishing. To that end, Fulcheri and Carrozzino (2017) have argued that tracking multiple facets of human experience is critical to enhance treatment effectiveness: ‘It is time to implement the relevance of positive clinical psychology for psychotherapy’ (p. 146).

Most recently, the second and third waves of positive psychology have expanded our focus beyond the individual person to also consider the impacts of the groups and systems in which people live, work, and play. Lomas et al. (2021) described the advancement of positive psychology to capture dialectical perspectives, attend to culturally embedded strengths and capacities, and situate a person’s mental health within historical and systemic contexts that may be counter to well-being. These are significant advances in increasing the applicability and salience of positive psychology to meet the complexity and dynamic processes of group work.

Traditional outcome measures in group therapy research

Group psychotherapy can only gain respect as an effective treatment and be reimbursed by insurance companies if group researchers, like individual therapy researchers, work hard to support not only the effectiveness of group treatment but also its equivalence to individual interventions (Whittingham et al., 2021). To do that, there has been a push to engage in randomized controlled trials comparing group and individual treatment modalities to address specific disorders. This has led to many studies and meta-analyses supporting the equivalence and effectiveness of group therapy using traditional outcome measures (Burlingame & Strauss, 2021). As an unfortunate side effect, it has also led to studies that often prioritize disorders and symptom reduction while neglecting other aspects of group therapy that help people in meaningful ways. In the past, group researchers often focused on curative relational and emotional mechanisms of group therapy (Marogna & Caccoma, 2014; Yalom & Leszcz, 2020); however, the need to compete with individual treatment has led to a shift away from these areas.

Currently, a majority of group therapy research prioritizes group cohesion, group climate, and changing symptoms (Rosendahl et al., 2021). It is rare to find studies exploring how group may facilitate changes in hope, empathy, or meaning in life or how positive group processes facilitate change - despite group therapy being the most frequently used treatment in most hospital and mental health settings (Whittingham et al., 2021). Further, online support group interventions are a promising new development to help people cope with the effects of the COVID-19 pandemic, such as loneliness, death anxiety, and grief (Brusadelli et al., 2021).

A notable exception to this focus on symptoms, Wei et al. (2021) explored the impact of positive emotions and positive relationships in group therapy on members, finding that positive emotional experiences in group had a powerful impact on group members’ well-being. However, among emerging group studies that do examine positive processes and outcomes, the focus is most often on hedonic well-being rather than the broader framing of eudaimonic well-being. To promote research and clinical integration that attends to more diverse and multi-faceted outcomes, we review below key domains of positive psychology salient in group treatment.

Integrating positive psychology in group research and treatment

Eudaimonic well-being is especially salient for group therapists, given group therapy’s unique focus on relationships and interpersonal functioning. Group therapy, unlike other treatments, addresses often-overlooked human aspects of experience, such as empathizing with people across difference, taking accountability for personal actions, developing gratitude, and learning to forgive. Through the integration of positive psychological factors and an emphasis on both social and emotional well-being, we can deepen and enrich clinical practice and build the evidence base. Seligman (1998) described six virtues that can be used as both process and outcome measures of group treatment and include: Humanity (e.g., attachment, belonging), Wisdom (e.g., reflective functioning, emotion regulation), Courage (e.g., taking accountability), Justice (e.g., fairness, appreciation of diversity), Temperance (e.g., humility), and Transcendence (e.g., gratitude, hope, forgiveness). We explore how each of these constructs can be understood as a source of vitality for group members, integrated in group therapy process, and used to examine multi-dimensional facets of treatment outcome and effectiveness.

Humanity: catalysing attachment and belonging

Fostering secure attachment

Lomas et al. (2021) argued that the concept of collaborative positive psychology - including connection and collective empowerment - is needed to facilitate positive transformation in groups. Years ago, Mikulincer and Shaver (2005) similarly suggested the notion of a positive social psychology, with attachment theory integrated alongside positive psychology to understand how relationships influence change. We concur that attachment theory (Bowlby, 1988) is an important measure of clinical change, describing the process by which individuals learn to adapt to their social environments to survive, beginning with the infant’s vulnerability and dependence on a dyadic caregiving. Attachment theory emphasizes the importance of emotion co-regulation and the ‘felt security’ (Sroufe & Waters, 1977) an infant relies on from caregivers when distressed. Children who have caregivers who are responsive, attuned, and able to provide a good enough sense of felt security often mature into adults who can rely on others when distressed and separate from close others to explore the environment.

Across the lifespan, attachment figures (e.g., parents, romantic partners, close others) can serve important functions in providing security and comfort amidst distress (Bowlby,1988; Sroufe et al., 2005). Adults with less secure attachments experience increased attachment anxiety and/or avoidance (Brennan et al., 1996). Attachment anxiety is related to hypervigilance and monitoring the environment for potential rejection and abandonment (Feeney & Noller, 1990) while attachment avoidance is related to compulsive self-reliance through deactivating the attachment system (Cassidy & Kobak, 1988). Mikulincer and Shaver (2016) have reviewed the extensive empirical literature linking insecure attachment to mental health concerns; building on this, McWilliams (2022) argued that facilitating safety and helping clients develop more secure attachments can significantly improve their relationships and well-being.

Group theorists and researchers have explored how attachment, used as a predictor variable, influences group members and leaders’ behaviours, as well as exploring how group can foster more secure attachment among members (Marmarosh et al., 2013). Maxwell et al. (2014) found that, after 16 sessions of Group Psychodynamic Interpersonal Psychotherapy, members reported reductions in attachment anxiety and avoidance, both of which were significantly related to decreased interpersonal problems at one year post-treatment, while reduced attachment anxiety was significantly related to decreased depression at one-year follow up. Interestingly, the significant relationship between reduced attachment avoidance and decreased interpersonal problems strengthened across time.

While a primary empirical focus has been on dyadic attachment (i.e., between two people), there is also evidence that people also have attachments to larger groups (Smith et al., 1999). Group identities, like attachment figures, bolster our self-esteem, regulate threats to personal identity, and provide comfort during painful times (Tajfel & Turner, 1979). Keating et al. (2014) found that the group members’ development of secure attachment with their therapy group was related to more secure attachment in a dyadic relationship one year after group therapy ended. Future research is needed to explore how increasing attachment security in groups relates to other meaningful outcomes, such as decreasing loneliness and increasing meaning in life and relationship satisfaction. As one example, Borelli et al. (2020) has applied attachment theory to understand how positive relational experiences can promote well-being by enhancing attachment security. Their intervention - relational savouring - emphasizes how moments of closeness with another person in treatment can promote flourishing in life more broadly. More such innovative research is needed.

Experiencing belongingness

One foundational mechanism of change in group therapy (and really any good group experience) is a sense of belonging and universality (Yalom & Leszcz, 2020). Belonging can be generally understood as feeling a part of a community, large or small, and knowing that one is welcomed and accepted. Universality is more specific and captures the experience of realizing that one’s experiences are shared by others, which leads to feelings of connection and belonging by countering the narrative that one is alone, isolated, and different. In group interventions, universality takes on specific meanings related to psychological and emotional suffering, as people struggling with mental health concerns often believe they are ‘the only one.’ This is particularly true with stigmatized conditions: greater stigma creates greater secrecy, which leads to greater shame and isolation, leaving many people to feel ‘unique in their wretchedness’ (Yalom & Leszcz, 2020, p. 6). Group therapy directly counters this belief and experience. Through the act of sharing with peers, group members reveal to each other that they share much in common, even the most shameful parts of themselves. This leads to an experience of universality - a shared understanding that the problems that members hid for so long (believing that they were the ‘only one’) are shared by others in the group. The fact that other members, who are often viewed as caring, respectable people, have the same concerns, counters the belief that there is something fundamentally and uniquely wrong with themselves.

In studies of group therapy, universality has been consistently identified by members as one of the most effective components of the treatment (Yalom & Leszcz, 2020). In research, most members report that the group experience led to greater universality and belonging, and when it did, this predicts greater symptom improvement. This link is evident in groups as varied as divorce support groups in Norway (Oygard, 2001), rehabilitation groups for sex offenders in Canada (Reimer & Mathieu, 2006), and computer-mediated groups for women with breast cancer in the U.S. (Weinberg et al., 1995). Universality and the sense of belonging that groups bring about are a major force in healing, and outcomes in their own right. There is real strength to be found in true connection with others, being a part of a larger community, and learning that personal struggles do not need to be hidden. Although Yalom and Leszcz (2020) have been writing about universality for many years, it is rarely included as a group outcome measure.

Wisdom: fostering trust, perspective taking, and emotion regulation

Cultivating trust and perspective taking

Seligman and Csikszentmihalyi (2000) described the importance of emotional intelligence and the capacity to understand another’s experience in addition to one’s own perspective. Relationship success and overall well-being are enhanced when people can empathize with one another and be curious about other views. Although Seligman did not elucidate a theory of mind, he did emphasize the value of people understanding the social world and being curious. Fonagy and colleagues (2002, 2017) have postulated that two key things emerge from secure attachment, which are critical to navigating the social world: i) the ability to take the other’s perspective, what they call mentalization or reflective functioning (RF); and ii) basic trust in others, which they term epistemic trust (ET). Both of these capacities are adaptive to human survival and relate to well-being, relationship satisfaction, and symptom remission; because of these links, we include them as vital signs in group therapy.

RF allows us to intuit others’ motivations and protect ourselves from threats, working in conjunction with empathy to understand and relate across different perspectives. Secure attachments, where caregivers are interested in and aim to understand the infant’s separate mind, create a safe enough environment in which the infant can begin exploring other people’s minds (Fonagy et al., 2017). Epistemic trust opens us up to take in information from a secure base relationship. Rather than relying solely on personal learning, ET allows us to accept information passed onto us from people experienced as benevolent and trustworthy. Although there have been many studies linking ET and RF to psychopathology and individual treatment (Fonagy et al., 2002), less attention has been given to applying these constructs in groups. As an exception, Fonagy et al. (2017) elucidated how therapy groups can foster RF by encouraging members to share different perspectives and addressing when assumptions are made about what another is thinking or feeling. When the group is functioning as a secure base, it facilitates members’ ability to tolerate painful feelings and explore others’ minds. When members’ fight or flight system is activated, instead of disengaging or becoming overwhelmed, the group can slowly gain insight into personal triggers and become more curious about their own and others’ minds and motivations. Tasca (2021) explained how RF can enhance therapy groups by considering how groups are affected by individuals’ mentalization. Building on this, Tasca et al. (2021) explored how attachment and RF can be addressed in group therapy and how a dynamic-interpersonal approach can facilitate growth in RF. Relatedly, Bateman et al. (2021) outlined how the process of repairing ruptures in group therapy can foster RF as group members seek to understand different perspectives and develop the capacity to tolerate and work through disagreements.

Although some attention has been given to RF in group therapy, there has been little research linking ET with group. In the context of insecure attachment, ET is compromised; thus, individuals are less open to the social knowledge that could guide them through the social environment. Fonagy et al. (2017) described how trauma can disrupt ET because caregivers become unreliable or distrustful sources of information about the world. Traumatized adults (and groups) learn to reject communications from others and outside groups that are inconsistent with their beliefs and perspectives. Although people are responding in an adaptive way to the painful social environment that exists, they are not open to new experiences, and thus may be at a disadvantage when rejecting important information that could ultimately be helpful. Group therapy researchers may want to explore how group can restore members’ basic trust in people and thus support ET development. This area offers exciting empirical possibilities, and though clinical wisdom would suggest such processes, ET in group has yet to be empirically examined.

Facilitating emotion regulation and transformation

Exploring, understanding, and modulating emotional experience is an explicit focus in many skills-based groups (Gratz et al., 2015; Harvey et al., 2019) and a joint interpersonal process in dynamic-experiential group approaches (Shore, 2020). Difficulties with emotion regulation (ER) is a transdiagnostic factor underlying psychological distress. A multi-dimensional construct, ER encapsulates capacities for self-regulation, co-regulation with a close other, and broader interpersonal regulation unfolding in a group context. Adaptive regulation processes allow clients to: i) more fully experience their emotional world, rather than dissociating or avoiding; and ii) use emotion productively as cues to underlying needs, desires, and motivations. Affective neuroscientific evidence points to both explicit (e.g., semantic) and implicit (e.g., relational) pathways toward ER (Messina et al., 2016, 2021).

Emotion transformation (ET) is an adjacent construct rooted in the sequential model of emotional processing (Pascual-Leone & Greenberg, 2007; Pascual-Leone, 2018). A growing body of literature indicates that emotions are understood, transformed, and given meaning through experiential processes in therapy, and that ‘nonlinear temporal patterns of moment-by-moment process relate to the unfolding of increasingly larger changes to create good psychotherapy treatment outcomes’ (Pascual- Leone, 2018, p. 165). ER and ET are particularly salient within group approaches, given the relational resources of the group.

The therapist has the opportunity to observe the spontaneous manifestations of phenomena, such as patients’ overreliance or underuse of the group to regulate emotions, help request/provision, adoption of adaptive/maladaptive strategies to regulate internal states in relation to other group members, and many others (Messina et al., 2021, p. 1).

Emotional processes have received growing attention in group therapy research, with the largest body of work focused on explicit self- and co-regulation strategies as primary treatment targets. Notably, ER is purported to be a central mechanism of change in Dialectical Behaviour Therapy; however, a recent systematic review found mixed evidence for ER improvements, citing methodological limitations (Harvey et al., 2019). Examining the effectiveness of Emotion Regulation Group Therapy, Gratz et al. (2015) found that reduced emotion dysregulation mediated symptom changes and predicted decreased selfharm at follow-up. More group therapy researchers are beginning to track changes in ER capacities in addition to symptoms, with promising changes noted (Sahlin et al., 2017; Spidel et al., 2018). Less has been empirically documented about the influences of implicit and interpersonal pathways to ER, yet neuroscience suggests that ER and ET are socially embedded capacities uniquely catalysed within group interventions (Grecucci et al., 2015), making this an important area for future research. Additionally, while theory and clinical wisdom suggest that the transformation of emotion is central to group work (Messina et al., 2021), research examining ET as an outcome has been limited to date by a focus on individual modalities. Given the centrality of emotion to human experience, these constructs offer promising new directions.

Justice: fostering well-being in marginalized groups

One important area often overlooked in positive psychology (Lomas et al., 2021), but critical to well-being and included in third wave frameworks, is the acceptance and integration of one’s identities, awareness of one’s impact on others, and insight into and adaptive responses to systemic forces (e.g., resilience and resistance to oppression). Justice serves as an over-arching virtue fuelling each of these areas of human experience, and third wave positive psychologists are now exploring how such domains are inextricably intertwined with well-being and flourishing. Researchers have demonstrated how discrimination, racism, and oppression can be damaging to people psychologically, emotionally, socially, and spiritually (Kirkinis et al., 2021). On the other hand, social psychologists have shown how a strong group identity can buffer effects of discrimination and how priming attachment figures can reduce discriminating behaviours (Mikulincer & Shaver, 2021). Group researchers have explored how groups can help people identify unconscious bias (Ribeiro, 2020), repair microaggressions (Miles et al., 2021; Lefforge et al., 2021), protect individuals from discrimination (Mikulincer & Shaver, 2021), and facilitate microinclusions and felt experiences of mattering (Wong, 2022). Group has unique potential to help people identify and expand on biases, explore the impact of their identities on others, and facilitate healing relational experiences in micro-social contexts (Stevens & Abernathy, 2018).

Ribeiro (2020) described the many ways group treatment can foster well-being to diverse members of groups, including addressing the struggles of people with different races, ethnicities, abilities, health issues, sexual identities/ orientations, and religious identities. Such approaches pro-actively address the unspoken isolation and loneliness that come from holding marginalized identities. As one example, Brave Heart et al. (2020) elucidated how group therapy can facilitate healing among people who have endured generations of trauma by developing an intervention to address the needs of indigenous populations in order to restore hope and well-being in the face of intergenerational oppression. Drapalski et al. (2021) tested a group intervention to address the stigma of serious mental illness, and found enhanced belongingness and reduced stigma, especially for those members with more serious psychotic symptoms. And Skinta et al. (2015) found that group compassion-focused treatment alleviated the stigma of HIV, which is noteworthy in that stigma is a painful struggle for many with marginalized identities.

Although there is a growing literature examining how group therapy can help members of marginalized groups and foster empathy across members’ differences, ongoing empirical work is needed. Researchers may want to explore how group therapy can empower marginalized individuals and communities who regularly experience discrimination. Relatedly, culturally adapted outcome measures are needed to meaningfully assess positive psychological constructs among survivors of intergenerational trauma, discrimination, oppression, and systemic racism.

Transcendence: supporting hope, gratitude, and forgiveness

Finding hope

Another positive outcome that has been assessed in group work is hope. Hope, generally, has been defined as a cognitive orientation composed of both perceptions of: i) one’s agency or determination to move toward goals; and ii) the means for achieving those goals, what Snyder et al. (1991) dubbed ‘the will and the ways’ (p. 570). Thus, hope is the sum of one’s will to achieve an end and the confidence about how to achieve it. The concept of hope also elicits a target - what one is hoping/hopeful for. In the context of therapy, this might include hope to recover or feel better, hope that therapy will be effective, or hope that despite the current pain, one can live a meaningful life. Can group therapy impact hope, helping people to gain more determination to achieve their goals and more awareness of the pathways available to them?

At a broad level, much of psychotherapy is about hope. Frank (1974) pointed this out with the use of the term ‘remoralization,’ stating that therapy is often about the process of helping people regain the will and way to engage with life. In fact, Frank argued that hope was often the initial ingredient that led directly to the reduction of symptoms that brought the client to therapy in the first place. There is some recent empirical support for this claim. In a unique test of remoralization and symptom reduction, patients with panic disorder in standard care and in remoralization treatment both reported reduced symptoms and increased hope (Vissers et al., 2017). The treatment approach used which that focused on increasing hope also reduced panic symptoms. Likewise, the intervention focused on panic symptoms also helped increase hope. This study, however, was limited to an individual treatment modality.

Group therapy studies have also linked group treatments with increased hope. In a study of the relationships among cohesion and hope, group members reported that the group experience led to greater cohesion, which led to greater hope (Marmarosh et al., 2005). In a related area, research on interventions to promote forgiveness have also found growth in hope. Wade et al. (2014) conducted a meta-analysis of 52 outcome studies of forgiveness interventions, showing that forgiveness treatments led to significant increases, not only in forgiveness (see section on Forgiveness that follows), but also in hope. Although not all interventions included used a group format, results remained significant when controlling for treatment modality, suggesting that both group and individual approaches promoted the development of hope. Future studies are needed to explore both the genesis of hope in group therapy, as well as the interplay between hope and other virtues that may develop in tandem, and thus, would need to be included together as salient clinical outcomes to track across time.

Cultivating gratitude

Gratitude has been described as ‘a catalysing and relational healing force’ and ‘one of life’s most vitalizing ingredients’ (Emmons & Stern, 2013, p. 846). Cultivating gratitude has gained increasing traction in recent years as part of mindfulness, self-help, and spiritual practices. As a virtue and cognitive-affective process, gratitude involves both: i) ‘an affirming of goodness or ‘good things’ in one’s life; and ii) the recognition that the sources of this goodness lie at least partially outside the self’ (Emmons & Stern, 2013, p. 847). Meta-analytic evidence suggests that gratitude can promote well-being, life satisfaction, positive affect, and decreased depression (Dickens, 2017). Not surprisingly, group interventions have been developed to promote gratitude in diverse contexts, including individuals with physical disabilities (Makarem & Yousefi, 2021), forensic and substance abusing populations (Allen et al., 2014), natural disaster survivors (Chan, 2008), athletes (Gabana et al., 2022), college students (Wong et al, 2017), and older adults (Safarzadeh, 2019). Furthermore, researchers such as Tomasulo (2017) are developing novel approaches incorporating cultural elements of storytelling and role-playing to make gratitude-focused groups more culturally responsive and to remove barriers to access.

Despite a proliferation of gratitude group interventions, much remains unclear about the mechanisms and pathways by which gratitude develops as well as cultural nuances in its expression. What group processes might uniquely contribute to the vitalizing energy that gratitude brings? For example, while behavioral gratitude practices can be completed individually (e.g., a gratitude journal), the emergent relational processes central to group frequently involve giving and receiving support, empathic witnessing, and constructive feedback. These exchanges may be particularly facilitative to increasing clients’ inthe- moment awareness of group members’ heartfelt contributions, from which feelings of gratitude may naturally emerge and be processed together. Gratitude has been postulated to help solidify and strengthen relationships by facilitating upward spirals of mutually responsive and altruistic behaviours that foster connection and belonging for both giver and receiver (Algoe, 2012). However, with the exception of gratitude-focused interventions, this virtue has been glaringly absent from group research as a whole. Research is needed to track changes in engagement with gratitude across the life of a group in order to better understand its development and associations with other relevant constructs, such as the group alliance.

Facilitating forgiveness

Forgiveness is another outcome salient to group therapy. Forgiveness can be understood in many ways depending on the target (e.g., forgiving others, self, communities, deities) and the ‘location’ (within one person or group, or between people or groups). Most of the psychological literature on forgiveness has focused on forgiveness of others or the self that occurs within the person(s) hurt, with renewed relationships between offenders and victims labelled reconciliation (Tucker et al., 2015). The literature in this area can be explored in both general and specific ways. Generally, forgiveness can result from group therapy, even without forgiveness being a targeted outcome per se. Through the process-oriented work of a therapy group, those who have been hurt are likely to share about those experiences, name personal impacts, and receive care and compassion from other members in the journey toward repair. This can lead to a series of beneficial outcomes, one of which might be a greater tendency to forgive offending person(s). For example, in a study of group treatments for PTSD in incarcerated women, treatment also led to increases in forgiveness, particularly for women in the experimental group (Ford et al., 2013).

More specifically, there is a solid literature on interventions intentionally designed to promote forgiveness. These have been offered in various modalities, including group, individual, couples, and even community-wide interventions. Meta-analyses indicate that these interventions are effective in promoting forgiveness (e.g., Wade et al., 2014). Furthermore, although both general and specific treatments can promote forgiveness, those that are explicitly designed to promote forgiveness appear to be more beneficial. Future research is needed to see how facilitating repairs of ruptures in groups may encourage forgiveness and how fostering forgiveness in group may generalized to outside relationships and broader well-being.

Courage: developing personal accountability

One area receiving more attention as of late is the virtue of accountability, which includes taking responsibility for both one’s part in an experience and being aware of personal impact on others (Peteet et al., 2022). This requires empathy and the ability to reflect on another’s experience. Peteet et al. (2022) explored accountability and how it can evolve from social experiences, resulting in positive impacts on both physical and mental well-being.

In group therapy, members learn to take responsibility for their behaviours in the group (Yalom & Leszcz, 2020). If a member is late, does not pay for sessions, interrupts others, is overly accommodating, or is passive aggressive, members learn to gently challenge these behaviours in order to help each other take ownership of their contribution to relationship difficulties. Yalom and Leszcz (2020) described members giving feedback and gaining insight as key aspects of groups in the working phase, including sharing their honest reactions about the ways other group members and the leaders impact them. When members struggle to take in feedback, leaders and other members aim to help the members explore and understand their defensiveness. Leaders often prepare group members for this process by describing the group process and format ahead of time as well as inviting members to share their reactions in real time. Through this, members gain insight into their contribution to conflicts and ruptures in the group rather than blaming others for their struggles. Newer research has focused on ruptures and repairs in group therapy (Marmarosh, 2021); building on this, studies are needed examining potential changes in: i) locus of control from external to internal responsibility; ii) openness to feedback; and iii) productive awareness of how one’s behaviours impact others.

Temperance: cultivating humility

Humility is another outcome with significance for group therapy. While definitions vary, psychological researchers largely define humility as a multi-dimensional virtue involving: i) accurate awareness of self, including limitations and strengths; ii) an appreciative openness to and orientation toward others; and iii) the capacity to regulate intense emotions, particularly pride and shame (Ruffing et al., 2020). Some even call humility a ‘master virtue’, which if practiced, may contribute to the development of other positive psychological capacities (Lavelock et al., 2017, p. 287).

Research on humility in therapy consistently evidences the salutatory influence of clinician humility, including cultural humility, on clients’ outcomes (e.g., Mosher et al., 2017; Sandage et al., 2016). However, there are considerably fewer studies examining the place of client humility in therapy, though scholars have begun theorizing about how clients may grow in humility through relationally oriented therapies, for example. One pathway may be through the therapeutic relationship itself, especially if the therapist models an authentically humble posture. In contrast with the Aristotelian proposition that individuals develop virtue in themselves, Sandage et al. (2016) elevated Plato’s philosophical perspective that virtues can also be gifted and received, suggesting that perhaps ‘struggles, fluctuations, disappointments, and ruptures in the [therapeutic] relational process drive the acquisition of humility as much, if not more so, than the individuals themselves’ (p. 306).

Group therapy may be an optimal context for humility development, as relational learning unfolds in real time with a clinician and other group members. Humility is likely a mechanism for change and a treatment outcome. For an effective group process, humility would be necessary to establish trust, refrain from dominating group processes, repair conflicts, offer and receive feedback, and learn from others’ perspectives. In one study, experiencing a therapy group as culturally humble was associated with improved individual outcomes (Kivlighan et al., 2019). Over time, clients may internalize humility as they ‘engage in behaviours that either mimic or are evidence of a humble disposition’ (Rowden et al., 2014, p. 382) and experience humility in others. Literature on the treatment of narcissism in a group modality also suggests a group’s potential to challenge ‘difficulties related to shame, dependency, self-sufficiency, and contempt for and envy of others’ (Yakeley, 2018, p. 311), all of which are relevant for avoiding the grandiose and self-deprecating poles that healthy humility lies between (Jankowski et al., 2021).

Catalysing meaning in life

Psychotherapy has not always attended to existential areas such as meaning in outcome research, despite evidence that meaning-making is a key component of eudaimonic well-being and resilience following stressful life events (Park, 2010). Wong (2020) argued that mainstream therapeutic approaches do not always address the unique existential needs stemming from complex, intersecting losses of our time, and called for integration of more inclusive frameworks such as existential positive psychology. Meaning is a key existential pillar, and is thought to include three facets, namely: i) coherence, which is a sense of one’s life making sense; ii) purpose, which involves clarity about core goals or aims in life; and iii) significance, which includes a sense of life as valuable and worth living (Martela & Steger, 2016). Clinical research indicates that clients are deeply invested in discovering - or creating - meaning in their lives (Hill, 2018), yet the search for meaning can be anxiety- provoking and stressful, and a persistent lack of meaning has been associated with higher risk for suicidality (Schnell et al., 2018).

Meaning-making is increasingly being integrated in some therapeutic approaches but has often been framed as an intrapsychic process. However, in many cultures, meaning-making is inherently social and relational; family members, friends, fellow survivors, colleagues, faith communities, and mental health professionals may play important roles in the creation of meaning (Walsh, 2007). Considering this, group modalities are uniquely poised to catalyse meaning-making processes. As one’s experiences are heard and held by the group, therapeutic processes of empathic witnessing, mirroring, validation, and companioning can help members metabolize previously unbearable affects and develop a greater sense of coherence.

In group therapy, the largest body of work attending to meaning as a primary outcome has been interventions tailored to those facing chronic suffering and mortality. For example, Meaning-Centred Group Therapy has been found effective in increasing meaning among terminally ill cancer patients (Breitbart et al., 2015; van der Spek et al., 2017). In the context of the COVID-19 pandemic, group interventions attending to ruptures in meaning (e.g., moral and existential struggles) have been found beneficial for nurses (Haddadi et al., 2021) and chaplains (Captari et al., 2022). Novel group approaches are also being developed that privilege the ways collective meaning-making is facilitated in diverse cultures, such as integrating expressive arts with domestic violence survivors (Murphy, 2021) and storytelling with refugees (Bunn et al., 2022). While attention to meaning is an underlying thread in many group approaches, much remains to be explored in research about both the explicit/verbal and implicit/non-verbal avenues by which groups promote the creation of meaning, as well as potential barriers and complexities that may arise (e.g., when group members arrive at contradictory meanings). Examining meaning transformation in group therapy for survivors of suicide, Supiano et al. (2017) utilized treatment process analysis, an example of one such study design that can facilitate nuanced exploration.

Practical implications for clinical work and training

Orienting treatment beyond symptom reduction to include attention to these vitalizing forces offers exciting possibilities to deepen and expand the reach of group therapy and help clients draw on culturally embedded strengths. However, in this new territory, therapist self-awareness and cultural humility are critical in order to meaningfully explore and deconstruct the diverse ways these constructs may be understood, valued, and embodied across cultures, recognizing that positive psychology has often centred Eurocentric perspectives (Paquin et al., 2019). These constructs ‘are necessarily embedded in a cultural context’ (Sandage et al., 2003, p. 571), and nuanced clinical engagement is needed, including consideration of members’ intersectional identities, social location, and context. Not all virtues will promote well-being for any one member. Scholars have elucidated the phenomenon of burdened virtues, capturing how inequitable societal conditions often necessitate oppressed groups developing ‘virtues that carry a moral cost to those who practice them’ (i.e., supporting survival but not flourishing; Tessman, 2005, p. 1). It is also important to assess for virtue bypass within group, wherein a supposed vital sign may be embodied to: i) repress and deny one’s own emotions and needs; or ii) oppress and subjugate others (Captari et al., in press). For example, a member who engages forgiveness defensively may rush to repair a rupture, bypassing the authentic process of working through anger and hurt; or a member who often puts a positive ‘spin’ on things may appear to embody hope but could also be slipping into a rescuer/fixer role while bypassing their own struggles.

From the perspective of virtue ethics, practical wisdom serves as a guiding light in helping clients reflect on which positive psychological constructs would be most vitalizing for them at the moment. This will likely vary significantly based not only on client characteristics, but also phases of treatment. Drawing from the positive psychology literature, this practice-friendly review has been illustrative, but not exhaustive. Constructs like compassion, courage, creativity, joy, love, patience, and authenticity, among others, are also worth tracking and exploring in group therapy. To add further complexity, while we have summarized these constructs one at a time, in the crucible of group process, multiple virtues often operate in tandem and interact with one another. For example, one member’s humility and self-compassion may encourage another member’s authenticity, and a leader engaging courage and hope to challenge group avoidance may open up new territory for trust and perspective-taking.

Training, supervision, and consultation are needed to: i) integrate these domains in practice with sensitivity to client diversity; and ii) develop critical awareness of our own assumptions about these virtues and consider their salience in professional development. Group therapy presents bountiful opportunities for therapists to develop these capacities, particularly in being mindful of privilege and difference and navigating moments of tension/potential rupture. Considering this, it would be advantageous to attend to these constructs in group therapy courses and supervision. Engagement with these vital signs can take many forms, ranging from group protocols focused on development of particular areas (e.g., gratitude, meaning) to much broader attunement to these constructs within group as a whole.

This review has argued for the import of positive psychological factors as clinical outcomes worthy of empirical investigation. However, more complex research designs are also needed to better understand how these constructs may function at times as both process and outcome variables. While research studies often focus on process or outcome in order to utilize specific statistical analyses, in clinical practice, these virtues are likely engaged with in dialectical and dynamic ways. Innovative work in this area will support the elucidation of core competencies for integrating virtues and positive psychology in group psychotherapy practice.

Funding Statement

Funding: this project was supported by grants from the John Templeton Foundation on ‘Mental healthcare, Virtue, and Human Flourishing’ (No. 61603) and the Peale Foundation.