How Can Group Leaders Address Culture in Small Groups? 

Implementing a new group psychotherapy protocol within American Indian communities

Yellow Horse Brave Heart, M., Myers, O., Skipper, B., Schmitt, C., Chase, J., Elkins, J., & Mootz, J. (2020). Iwankapiya American Indian pilot clinical trial: Historical trauma and group interpersonal psychotherapy. Psychotherapy, 57(2), 184-196. doi: 10.1037/pst0000267.

Minority groups have been underrepresented in group psychotherapy research (Paquin, Tao, & Budge, 2019). This study is being highlighted because it exemplifies a current effort to address this gap. The authors study the effectiveness of a well-established group protocol adapted to meet the needs of a particular cultural group: American Indians (AI) diagnosed with depression. 

Using an additive design, the researchers randomly assigned participants to group interpersonal therapy or group interpersonal therapy enhanced with the Historical Trauma and Unresolved Grief intervention (HTUG). This is an intervention designed for American Indian populations in which depression and grief are framed in terms of internalized oppression and associated trauma and loss (Brave Heart, 1998). Both experimental conditions were structured in nature, 12 weeks long with one 2-hour session per week, and were led by senior clinicians (seemingly affiliated with the study authors) who were paired with either established providers or tribal college students in the AI community.  

While both treatment groups saw a reduction in depressive symptoms over time, the enhanced group treatment showed superiority on several important dimensions. Specifically, this condition resulted in greater group engagement manifested by better attendance and patients contributing in group discussions. Importantly, the therapists expressed a preference for the condition where the HTUG component was added to the interpersonal therapy group. 

Clinical and Research Implications: Much is to be learned from the experience of these authors, including (but not limited to):

  • The study provides a framework for studying the effectiveness of a group psychotherapy protocol within a minority community. 
  • The authors list several obstacles they encountered while trying to implement the psychotherapy protocol in tribal communities. For instance, transportation issues or poor access to cell phones made it difficult for patients to consistently attend treatment. There was an obvious need for emotional support for therapists given the difficult nature of their work. The authors’ experience suggests navigating implementation barriers may require as much attention by clinicians and researchers as developing psychotherapy protocols adapted to a population’s specific needs. 
  • Patients in the study reported appreciation for the HTUG intervention because it considered historical events of their culture (e.g., trauma associated with boarding schools). Clinicians would be wise to be informed on historical events relevant to minority communities with whom they work. 


Brave Heart, M. (1998). The return to the sacred path: Healing the historical trauma response among the Lakota. Smith College Studies in Social Work, 68, 287-305, doi: 10.1080/00377319809517532.

Paquin, J., Tao, K., & Budge, S. (2019). Toward a Psychotherapy Science for All: Conducting Ethical and Socially Just Research. Psychotherapy, 491-502, doi: 10.1037/pst0000271.

Addressing microaggressions in group therapy: A training model

Lefforge, N. L., Mclaughlin, S., Goates-Jones, M., & Mejia, C. (2020). A training model for addressing microaggressions in group psychotherapy. International Journal of Group Psychotherapy, 70(1), 1-28. 

The term microaggression was first used by Pierce (1970) in the wake of the civil rights movement to refer to subtle discriminatory statements or acts that were seemingly innocuous. Sue et al. (2007) expanded this definition in a taxonomy of microaggressions, identifying specific types of these “commonplace verbal, behavioral, or environmental” injustices (Sue et al., 2007, p. 271). Research has demonstrated the high prevalence of microaggressions in psychotherapy. For example, in a sample of 2,212 racial and ethnic minority (REM) clients, over 50% reported experiencing one or more microaggression during psychotherapy (Hook et al., 2016). In another study, Owen et al. (2014) found that 53% of clients experienced at least one racial microaggression and 76% of those participants reported that it was never addressed in session. The prevalence of microaggressions in group therapy is similarly problematic.

Belcher Platt (2017), for example, examined racial-cultural events (RCEs) in group therapy utilizing a grounded theory approach. Findings suggested that not only were microaggressions present in therapy groups, but their processing  was impeded by group discomfort, group composition and dynamics, and external experiences of RCEs. In another study, Kivlighan and colleagues (in press) found that 72% of participants reported experiencing at least one racial microaggression over the course of their group therapy experience. Taken together, this research suggests that microaggressions occur regularly in psychotherapy, and that these cultural ruptures often go undetected and unaddressed.

Although there has been a great deal of attention to how to attend to microaggressions in individual therapy, less attention has been paid to the occurrence and impact of microaggressions in therapy groups until recently. In our highlighted article, Lefforge and colleagues (2020) developed a model to train group therapists to identify and address microaggressions as they occur in group therapy. This multimodal training includes didactic elements aimed at increasing trainees’ knowledge of various concepts from the multicultural and social psychology literatures (e.g., microaggression, implicit bias, and intersectionality; social dominance theory). The model also provides opportunities for experiential learning through the use of videos and fishbowl role-plays to illustrate the concepts introduced in the didactic portion of the training with the goal of helping trainees “gain comfort with dialoguing about these topics” (p. 15). 

An important element of the model is the “time out” function during the experiential portion, where participants can pause the group process and gain in vivo feedback from other participants. For example, leaders can pause the group and ask whether their interventions are helpful (or not). Lefforge and colleagues noted that, “Responding therapeutically to microaggressions requires cultural humility, perspective taking, and advanced interpersonal skills” (p. 23). Thus, their multimodal training aims to not only enhance trainees’ knowledge and awareness of the presence and negative effect of microaggressions, but also the skills in addressing microaggressions in group therapy.

Lefforge et al.’s (2020) training model is an important first step in training leaders to be more effective in addressing microaggressions in group therapy; however, empirical research is need to test the effectiveness of this approach. In addition to examining the presence and effect of microaggression on members of therapy groups, research is needed to identify best practices in training group therapists to address microaggressions in therapy groups.


Belcher Platt, A. A. (2017). Racial-cultural events and microaggression in group 
counseling as perceived by group counseling members of color.
(10607840). Doctoral dissertation. Fordham University. ProQuest Dissertations & Theses Global: Social Sciences.

Hook, J. N., Farrell, J. E., Davis, D. E., DeBlaere, C., Van Tongeren, D. R., & Utsey, S. O. 
(2016). Cultural humility and racial microaggressions in counseling. Journal of Counseling Psychology, 63(3), 269–277. 

Kivlighan III, D.M., Swancy, A.G., Smith, E., & Brennaman, C. (in press). Examining racial microaggressions in group therapy and the buffering role of members’ perceptions of the group’s multicultural orientation. Journal of Counseling Psychology. 

Owen, J., Tao, K., Imel, Z., Wampold, B., & Rodolfa, E. (2014). Addressing racial and ethnic microaggressions in therapy. Professional Psychology: Research and Practice, 45(4), 283–290.

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