Feasibility of a Novel Online Cross-Residency Group Dynamics Course with Didactics, Experiential T-Group, and Review.

To the Editor:

Courses in group dynamics or group psychotherapy often include both didactics and an experiential group [1, 2]. In psychiatry residencies, some experiential process groups are mandated, which ensures sufficient participation for the group to occur but takes away the choice to opt-out, and some groups are voluntary, which can lead to problems with sufficient participation. In this letter, we describe a novel approach which allows for voluntary participation and sufficient numbers by including residents across multiple programs in an online format. This course was offered online during the COVID-19 pandemic, when most courses in residency programs were also online, which allowed participation across a wide geographic area. In addition, this project was funded by the Duke Program of the North Carolina Area Health Education Center (AHEC) to build connections and share educational resources across psychiatry residency programs in North Carolina, as there are four newly started psychiatry residency programs in recent years.

The course used the Zoom videoconference platform and consisted of twelve 75-minute sessions. Two initial orientation/didactic sessions included brief experiential activities to assist residents in warming-up to the online format and to cultivate psychological safety, promote multicultural awareness, and foster group cohesion. These two sessions also included a review of core concepts in group dynamics and orientation to the experiential T-group. A T-group — sometimes called a “process group” or “training group” — is a group which studies its own members’ behavior with the goal of increasing understanding of interpersonal and group dynamics [3]. The T-group orientation involved reviewing learning objectives, differences between a therapy group and a T-group, and a specific set of group agreements. To address the online setting, one group agreement explicitly called for participating from a private location with videos and mics on.

Orientation was followed by eight sessions of the experientially focused T-group. After each session, residents were sent a set of consistent reflection prompts. Resident answers to the reflection prompts were compiled and returned to each group member ahead of the seventh T-group session. The course concluded with two sessions focused on reflection, review, integration of didactic material with the group experience, and plans for application.

Instructors recruited ten residents, focusing initially on psychiatry programs within North Carolina and then opening recruitment nationally. Residents from six different training programs were included. Two discontinued for personal reasons. Diversity, equity, and inclusion were important considerations in the course. Instructors began the orientation sessions by discussing their own social identities, including dominant and marginalized aspects of their selves. The instructors also presented limitations of T-group theory, including that it is culture-bound, and invited residents to question assumptions around behavioral norms in T-groups.

After the course concluded, the opportunity to write together about the experience was offered to all residents. Four residents chose to contribute and their reflections were collected after completion of the course for the purpose of writing this letter. Prominent themes centered on structure, experiential learning, emotional vulnerability, and the impact of technology on the learning experience.

During the initial T-group sessions, residents discussed the structure and noted the absence of universally shared expectations regarding how such groups should operate. At least one participant had anticipated a “lecture-based” or didactic experience, while others had entered anticipating some ambiguity. Another participant found the introductory sessions helpful in establishing a shared framework.

There were a significant number of reflections regarding experiential learning. In the words of one participant, “I found the T-group to be a valuable experience not only in learning more about myself in groups but also in observing others’ participation in the group.” Several other residents also appreciated the intrapersonal and interpersonal learning opportunities, including the ability to seek and provide real-time feedback. Some of the feedback allowed for explicit reflections regarding culture and identity within the group. The experiential nature increased individual self-awareness and it increased awareness of the importance of psychological safety and emotional vulnerability.

From the perspective of the resident authors, virtual participation was also associated with technical challenges like screen fatigue and small screen sizes when joining with a mobile device. Emotional distancing caused by the lack of informal encounters was reported as a challenge to building psychological safety. One participant said, “Logging onto my computer and seeing different participants’ faces come up at the beginning of the session and immediately disappear at the end of the session created a sort of emotional distance on top of the clear physical distance from other members.” Additionally, feedback was provided about difficulty with providing and following non-verbal cues and relying primarily on verbal reports.

From the instructors’ perspectives, there were challenges relating to design, recruitment, and implementation. As one example, it was important to create an inclusive learning environment, yet challenging to know what the group composition would be without asking questions about social identity in the initial registration process.

All the authors report that while the online structure allowed for some form of connectedness, it also contributed to a sense of distance within the T-group that was an unfamiliar experience. For example, one participant felt that the online nature of the group allowed greater comfort, while other participants felt that the physical distance combined with the impermanent nature of the group created some apprehension regarding vulnerability within the time-limited context.

Experiential T-groups have historically been included in many psychiatric residency training programs [4], though fewer in recent years [5]. To our knowledge, there has been no prior report of an online group dynamics course with an experiential T-group composed of psychiatry residents from multiple programs and, with this project, we learned that it is feasible. We also found some challenges in creating connections and promoting emotional vulnerability that may require creative approaches. Future attempts might address this by modifying the group agreement to include logging-on to the video platform five minutes ahead of the start time, even if still traveling to the private location, to create some of the informal “down time” that exists in most in-person group meetings. Another potential strategy is to pilot a hybrid model with in-person sessions along with online sessions. Lastly, formal assessment with pre-course and post-course questionnaires may uncover further areas for improvement.