Spirituality, Security, Compassion, and Play: Innovative Ways Group Psychotherapy Addresses Human Suffering

ABSTRACT

We are surrounded by trauma, grief, pandemics, health care inequality, poverty, climate change, and social injustice, not to mention increases in suicide, depression, and loneliness. How can group therapists address these issues and thrive? The current special edition focuses on how groups foster compassion, provide spiritual healing, and address human suffering in effective and innovative ways. Instead of focusing on symptom reduction alone, group therapists and researchers are exploring ways that group therapy can provide healing and resources to people including health care providers, and those who are on the front lines. The current special edition will highlight how spiritual interventions, compassion and attachment-focused interventions, and group interventions can engender positive outcomes for diverse group members that include parents of inner-city children to first responders. If there ever was a time for us to focus on compassion, faith, and forgiveness, it is now.

As the new editor of the journal, I was tasked with developing a special edition that would be useful to group therapists practicing in a world that is divided, where there is polarization, hate, racism, and unimaginable loss. The journal has had papers devoted to war, to trauma, and to racial reckoning, but there was less attention to the things humans hold on to when they are suffering, and that includes spirituality, compassion, play, and forgiveness. When looking back, a handful of papers explored spirituality in group therapy (Cornish et al., 2013; Goodman & Manierre, 2008). Some approached the topic of love (Fieldsteel, 1984), passion (Billow, 2002), joy (Saul & Saul, 1990), and hope (Saakvitne, 2005).

The field of psychotherapy research and practice has been shifting toward more-nuanced outcomes than symptom change or interpersonal skill development. Although we all aim to reduce depression and anxiety as well as improve relationship-enhancing behaviors in group therapy, we also seek to foster group members’ sense of purpose, gratitude, cultural humility, and compassion for self and others. Yalom and Leszcz (2021) describe the therapeutic factor of hope and existential meaning that comes from participating in group therapy. These outcomes, often referred to as positive psychological variables, also include spirituality, joy, connection, and flourishing (Marmarosh et al., 2022).

Many authors submitted their work to the journal, and this led to several papers for the special edition and the need to divide them across two issues. This is the first. It includes papers that address the importance of play in groups (Sadka et al., 2024), parent group telehealth interventions that foster trust and connection for at-risk children (Kucer et al., 2024), the emphasis on compassion in group treatment (Erekson et al., 2024), spiritual interventions to address human suffering (Captari et al., 2024), and spiritual group interventions that foster forgiveness to first responders coping with post-traumatic stress disorder (PTSD) and substance use (Kaufman & Rosmarin, 2024).

PLAY IN LIFE AND IN GROUPS

Laughter, joy, and spontaneous engagement in connection with another person is one of the most enjoyable and underrated experiences in therapy, if not in life. I was recently reminded of this when my father was diagnosed with an incurable lung cancer last year. Before my father passed away, one of the best memories was playing a “get to know you” game with him and my mother. The three of us, a very small group, sat down and started to play the game, and then he burst into laughter as he recalled memories of my parents’ early relationship. The two of them started to re-tell “crazy” stories about when my father first met my mother, and we laughed together. It was as if the cancer no longer existed for a brief moment in time. We all can recall the times we laughed the most and the people who we were with. Saul and Saul (1990) describe how “a good laugh can, and often does, reverse negative energy. The sharing of laughter develops a camaraderie which enhances group cohesiveness” (p. 326).

Grotjahn (1971) presented a brief commentary on laughter in group therapy and a few years later Rossel (1979) wrote a wonderful paper reviewing play and humor in group treatment. Rosell focused on Freud’s (1905) work and set the stage for the current paper, which uses a different lens, an attachment perspective (Sadka et al., 2024). In this issue, Sadka et al. (2024) describes how a supportive therapeutic group can promote members’ sense of attachment security, which is crucial for well-being. In their paper, they propose that the attachment security enhancement model (ASEM), which explains attachment processes that foster security, can also integrate playful group interactions that likely facilitate secure attachments. The authors provide a clinical vignette illustrating the therapeutic value of playful interactions and how they can be used to foster attachment security in groups. The authors suggest that positive group experiences can counteract their negative internal schemas of others and increase trust in the group. The positive feelings, such as joy while being in connection with others, can lead to more-secure internalized representation of group experiences. Instead of fears of being engulfed, shamed, or abandoned, group members may begin to feel a desire for closeness, fun, trust, and connection.

HELPING PARENTS HELP THEIR CHILDREN

Helping children who have suffered loss and adversity has been the focus of many papers in the International Journal of Group Psychotherapy. Some papers have addressed different interventions that include reaching out to inner-city children (Schamess et al., 1997). The current paper in this issue by Kucer et al. (2024) explores the effectiveness of an online, short-term, group-based parenting program designed to support families facing socioeconomic and health disparities. Because the group is online, it allows parents to attend the group who may not otherwise be able to participate. The theoretical background for the intervention is psychoanalytic (Fonagy et al., 2019) but the intervention is time limited. The authors studied 44 caregivers who were experiencing parent-child relational participation challenges, and they found that caregivers with high levels of parenting stress benefited from the intervention. The study is critical because the authors used measures that would allow Spanish-speaking parents to participate. Their sample was diverse and included 39% Latinx; 48% Black, African, or African American; 11% White; 7% Asian or Pacific Islander/Hawaiian; and 5% Native American or Indigenous. Unlike most studies that do not include a diverse sample of participants, these researchers included parents from different economic backgrounds and communities. Seventy percent of the caregivers were not married, and many caregivers recalled three to four adverse childhood experiences and exposure to community-level adversity such as neighborhood violence, bullying, racial discrimination, and foster-care placement. The results of this study are promising, and the intervention is effective for caregivers experiencing parenting stress, particularly those with conflicting work demands and limited access to transportation. Telehealth group interventions prove to be accessible and foster trust among group members, while meeting treatment-specific goals of improving parent-child relationships. The findings guide us as we aim to engage in more group-therapy-based social justice initiatives in the years to come.

FOSTERING COMPASSION IN GROUPS

It is not surprising that the increase in human suffering has paralleled the growing attention to compassion in psychotherapy. Compassion focused therapy (CFT) is based on the prioritization of human suffering by engaging with it and committing to alleviating it. In this issue Erekson et al. (2024) describe the history of CFT and the empirical evidence supporting it, and they apply it to group therapy (Barnes & Burlingame, 2016; Cattani et al., 2021). The authors clearly set the stage for CFT group therapy by presenting research describing the enormous amount of suffering that people are experiencing today. They then describe CFT as a transdiagnostic approach to psychotherapy that incorporates attachment theory, evolutionary psychology, neuroscience, Buddhist psychology, and mentality theory (Erekson et al., 2024). Their treatment group was 12 modules that can be extended over many sessions. The authors review each module: the “tricky brain,” emotions, mindfulness, feeling safe and accepting compassion, compassionate self, multiple selves, self-criticism, shame and guilt, deepening self-compassion, compassionate assertiveness, forgiveness, and compassionate future. Much of the group process focuses on addressing the fears, blocks, and resistances to compassion, which includes the lack of empathy for others.

A clinical vignette explores compassion in a group with eight members, and it focuses on the impact of culture and ethnicity on self-compassion. The clinical vignette highlights how family upbringing and collective culture influences the rejection of self-compassion and how the group process impacts members with different experiences of compassion. The application of CFT group therapy to diverse people with diverse backgrounds, races, and cultures is needed as we continue to explore how to address human suffering in group therapy.

SPIRITUALITY IN GROUP INTERVENTIONS

One way many people cope with suffering is through their spirituality and faith (Koenig, 2009; Pargament, 2007). Cornish et al. (2013) describes how group therapy addresses spirituality, and how this can foster group treatment outcomes when it is addressed in group therapy. Unfortunately, addressing spirituality has been plagued with ambivalence and misunderstanding, with few people publishing papers on the topic in the journal. Spirituality, unlike religion, is a broader concept of searching for the divine, or transcendent, that does not have to occur within an identifiable community or religious group (Hill et al., 2000). Pargament (2007) describes spirituality that can be related to a variety of religious and nonreligious affiliations and behaviors. For example, one can experience spirituality without attending church, a temple, or engaging in religious rituals. In times of distress, people can draw on a variety of distinctive spiritual/religious coping skills to sustain themselves psychologically, socially, physically, and spiritually. People can find support when social support is lacking, when struggles are overwhelming, and when life feels out of control (Pargament, 2007). Spiritual resources are an important aspect of individuals’ lives that clinicians can draw upon to facilitate health and well-being and reduce loneliness. Recent literature has included spirituality and religious identity within the area of diversity and respecting individuals’ beliefs, perspectives, and values as they enter therapy (Nguyen & Sands, 2020; Rupert et al., 2019; Winkeljohn Black et al., 2021).

Despite the limited attention to spirituality, Cornish et al. (2013) argue that spiritual struggles, religious values, and traditions are important aspects of people’s culture and group lives outside of group therapy. It is critical to welcome these intersecting identities into the group therapy setting (Ribeiro, 2020; Wade et al., 2014). Two papers in this special edition focus on spirituality in different types of groups. One focuses on reaching out to helping professionals who are suffering from burnout with an online group intervention (Captari et al., 2024); the other focuses on helping first responders by using a one-session spirituality-based forgiveness group intervention (Kaufman & Rosmarin, 2024).

Group Intervention for Health Providers

Captari et al. (2024) developed an online intervention specifically for helping professionals (HPs; i.e., mental health professionals, chaplains, clergy) that is designed to address burnout and vicarious traumatization and promote well-being and flourishing at work. In contrast with most self-care-focused models addressing work stress, the CHRYSALIS (catalyzing helping professionals resilience, vitality, spirituality, authentic living, and inner strength) intervention focuses on groups, incorporates cultural and spiritual contexts, and attends to systemic challenges. The online group format entails eight sessions exploring strengths that can promote well-being. In this study, the authors analyzed data from 41 helping professionals who were randomly assigned to the group condition and completed surveys at baseline, midway through the study, at termination, and 2 months later. Results indicate significant decreases in burnout and vicarious traumatization, as well as increases with well-being at work. The authors explored the qualitative data, and it suggested that the group intervention enhanced relational support, fostered different perspectives, and increased appreciation of personal strengths. The online group intervention addresses the high burnout of health providers and applies group intervention to helping the helper. Often, we focus on helping designated patients in group therapy, but this important work reminds us of how we also need to reach out to health providers. The increasing suicide rates for health care providers (Dutheil et al., 2019) along with burnout (Tawfik et al., 2019) are issues group therapists need to address.

Spirituality Interventions for First Responders

Rosmarin et al. (2019) developed a spiritual group therapy intervention for patients with chronic and severe mental illness, called SPIRIT: spiritual psychotherapy for inpatient, residential, and intensive treatment. The intervention was designed to bring spirituality to inpatient treatment during which patients often feel lonely, isolated, and afraid. The group-based intervention was successful, and most of the patients reported that the group intervention facilitated a deeper understanding of how spiritual struggles (e.g., loss of meaning in life, existential distress) and issues related to their symptoms (e.g., depression, anxiety, trauma) and how they could rely on their spirituality to cope with their mental health struggles (Rosmarin et al., 2019).

In this edition, we present Kaufman and Rosmarin’s (2024) revised SPIRIT group intervention for first responders, who often struggle with PTSD and substance abuse. First responders (e.g., firefighters, law enforcement, paramedics, corrections officers) often experience high rates of trauma and alcohol use disorder (AUD) and need intervention. Spiritually integrated group interventions for this population are rare and have not been a focus in the past in the journal. Kaufman and Rosmarin (2024) describe the forgiveness session of a spiritually integrated group psychotherapy protocol for first responders (SPIRIT-FR) in acute psychiatric care. This brief group psychotherapy intervention included psychoeducation, discussion of the relevance of forgiveness to PTSD and AUD, and the integration of spiritual beliefs and behaviors to move toward forgiveness. Although the intervention is brief, it highlights the need for accessible group interventions that can be applied to settings outside of the traditional psychotherapy session. As we aim to address health care disparities and human suffering, group therapists may be applying their training to shorter interventions that help people who do not come to therapy but need help.

CONCLUSION

All of these papers in this first special edition focus on alleviating human suffering, and the authors do this in creative and novel ways. Sadka et al. (2024) focuses on the use of play in group psychotherapy aimed at fostering secure attachment. Their work invites us to develop research methods to study play, humor, and laughter in group therapy. Creatively, they use attachment theory to focus on how positive experiences can engender as much growth and change in attachment as painful ones that are shared in treatment.

Kucer et al. (2024) implement online groups to reach out to diverse inner-city parents who are struggling with child relationship issues as well as environmental stressors that include community violence, bullying, and financial hardship. They incorporate measures translated into Spanish and include people with diverse backgrounds who do not have access to care. Even though they apply a psychoanalytic lens (Fonagy et al., 2019; fostering mentalization), they rely on a brief online group model to reach out to people in need. Their work blends analytic tradition in theory that emphasizes development and internal processes with contemporary modalities (online group treatment) and practical time restraints (12 sessions).

Erekson et al. (2024) presents a compassion-focused group model that is aimed at alleviating human suffering. Similar to Kucer et al. (2024), their approach integrates attachment theory and contemporary interventions that foster change. They invite us to explore how culture, family, and diversity factors influence compassion in groups. Their work can be applied to many different settings for people who are in need of mental health care.

The last two papers focus on applying our clinical work to people who are suffering and helping others. Captari et al. (2024) describes a spiritual online group intervention for health providers who are struggling with burnout. The results of their research suggest that brief group online interventions can help people who are helping others and suffering. Kaufman and Rosmarin (2024) describe how a one-session group intervention that focuses on forgiveness can help first responders struggling with PTSD and substance use.

Although I am a psychodynamic/psychoanalytically oriented group therapist at heart and prefer to work with patients in time unlimited groups, I also recognize the amount of suffering we are seeing in the world. Whittingham et al. (2023) described the bottle neck in health care and the limited access many people have to treatment. Despite the enormous suffering, many people are not getting the help they need.

One solution is using more group therapy and more focused group interventions that are based on diverse and complementary group theories that include brief psychoanalytic approaches (Whittingham et al., 2023). Exploring how our group interventions are helping diverse group members, using technology that allow individuals the opportunity to attend sessions (Weinberg & Rolnick, 2019), creating smaller communities for people who are alone and isolated, and “helping the helpers” by providing groups to first responders and health care professionals are all ways we can move the field forward. I hope that my leadership as editor of the International Journal of Group Psychotherapy will foster continued attention to human suffering and the creative ways that group therapists can make a difference.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Cheri Marmarosh

Dr. Cheri L. Marmarosh is a Research Professor at Divine Mercy University and the Director of the International Center for the Psychology of Spirituality and Mental Health. She is currently collaborating with researchers at Mass General and Dana Farber on research that will facilitate the wellbeing of patients diagnosed with incurable cancer. Dr. Marmarosh is also an Associate Professor of Clinical Psychology at the George Washington University and has been there for 18 years where she has been studying how attachment relates to coping with oppression, ruptures and their repairs to the therapy alliance, and outcome in individual and group psychotherapy. She has published over 50 empirical and theoretical articles that focus on how group and individual psychotherapy facilitate change. Dr. Marmarosh is the lead author of two books, Attachment in Group Psychotherapy and Groups: Fostering a Culture of Change. She participated in two videos demonstrating group psychotherapy for the American Psychological Association’s (APA) psychotherapy video series. She is a Board Certified Psychologist (ABPP), recipient of the Group Psychologist of the Year (Division 49), and she is a Fellow of the American Group Psychotherapy Association (AGPA), Division 29 (Psychotherapy), and Division 49 (Group) of the APA. Dr. Marmarosh is also a certified group therapist, past president for Division 49, and the current Domain Representative for Training/Education for Division 29 (Psychotherapy). Dr. Marmarosh has a private practice in the DC area and works with individuals, couples, and groups.She is the current editor for The International Journal of Group Psychotherapy.