The needs of people with mental health problems are increasing globally, especially following the turbulence of COVID.
Even before the pandemic, it was clear that despite more resources for mental health services in New Zealand and Australia, the prevalence of mental health problems was on the rise.
Mental health care in the current format is not meeting the needs of people living in the community, and there’s an ongoing shortage of mental health providers and relevant therapies.
In an unequal world, the rising burden of mental illness is often made worse by lack of access to quality evidence-based care. We need a new approach and it should focus on communities, scalability and equity.
In our recently published scoping review, we examine how group-based therapies could improve mental health outcomes.
Social factors are important
Many think of mental health care as involving a visit to a GP, psychologist or psychiatrist, a prescription for medicines and perhaps individual “talk therapy”.
But we wanted to examine the value of “psychosocial” care – a broader approach that meets individual needs but also considers social factors such as housing, income or relationships.
Our review aimed to understand the value of group-based interventions, recognising the importance of social networks and relationships for recovery across all communities.
Group interventions might typically mean weekly or monthly meetings with a regular group experiencing mental distress. These would be facilitated by peers or community members who have been through similar difficulties.
Our study focuses on communities with fewer resources in South Asia, including Nepal, India and Bangladesh. It takes a regional approach because we know context matters in mental health, and one size doesn’t fit all.
We considered group interventions that shared a cultural context to see if they better engaged people on a local level. As such, our findings are also relevant for addressing the mental health care gap in Aotearoa New Zealand. The value of relationships and whānau care is already well recognised for Māori.
There are also promising recent studies showing the value of group interventions for mental health among young people, and the contribution of kaimahi (non-regulated health workers) to improve outcomes for people with chronic conditions.
Why group-based therapy?
Group interventions have been shown to improve mental health outcomes in both community trials and systematic reviews. A recent meta-analysis of 81 studies showed talk therapy is the best initial treatment for depression.
If psychosocial interventions were a pill, their effectiveness would be trumpeted globally. Yet Western biomedicine (mental health care that requires psychiatrists and psychologists to deliver it) continues to command the majority of resources because of hierarchies and global economic structures that privilege psychiatry and medicines.
As well as being effective, there are other advantages to group-based interventions because they:
do not rely on expensive specialist providers
can be delivered in communities and therefore improve access to care
are responsive to local contexts such as groups in rural areas
improve outcomes for groups that typically experience worse health, including new migrants to New Zealand
increase engagement with mental health services
and are highly cost-effective and scalable.
Group therapy improves mental health and social connection and is at least as effective as individual therapy.
It can be used for a wide range of mental health problems and is more cost-effective than one-to-one individual therapy. In communities that have a more collective approach to health and wellbeing, such as Indigenous groups, mental health care delivered in groups can better reflect these values. This in turn may increase accessibility and uptake.
How group therapies work
Most quantitative health studies only ask whether a particular intervention works. But we used an approach that looks for how interventions work by examining the contexts, mechanisms and outcomes.
As well as examining effectiveness, a “realist” evaluation seeks to provide an explanatory analysis of how and why complex social interventions lead to improved health outcomes. This helped us assess what works, for whom and in what circumstances.
In this review of 42 peer-reviewed research publications, we identified five key mechanisms that groups offer to improve mental health:
They increase opportunity to be part of trusted relationships, which is a key social determinant of health. Group members described new friendships that continue after the intervention was over.
They trigger a sense of social inclusion and support, meaning people access resources and services more easily. Social inclusion is an important factor that determines mental health. Studies gave examples of how group members supported each other emotionally and with child care, agricultural and home responsibilities.
Groups can strengthen people’s ability to manage mental distress because they provide an opportunity to rehearse and use mental health skills and knowledge in a safe social space. This is key to building communication skills and self esteem.
They trigger a sense of belonging, and members can manage emotions better. This enabled behaviour changes. For example, widows in northeast India described how they were able to identify and control feelings of anger because of their sense of connection with the group.
Groups provide a sense of collective strength and can act collaboratively for their own wellbeing. Group interventions are particularly beneficial for minorities, such as non-binary and transgender people, who experience higher rates of mental distress as well as social exclusion. A group can offer social support and affirmation, which have also been identified as key mental health determinants.
These mechanisms are relevant in Aotearoa New Zealand as well as across the wider South Asian region we studied. The recent government inquiry into mental health and addiction, He Ara Oranga, underlined the value of non-biomedical and local solutions for mental health, including therapeutic groups. It called for a move from “big psychiatry” to “big community”.
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Group therapy fits well with a community approach as it can meet mental health needs without medicines, hospitals or expensive professionals. Psychosocial group therapies do not seek to replace formal mental health care. They complement it by providing accessible, cost-effective care in communities and among people who have unmet mental health needs.