The effectiveness of online group psychotherapy: A

systematic review
Protocol v1.0, 28 02 2023

Protocol authorised by:

Full name in print

Role Date Signature

Andreas Tzeremes 28/02/2023

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 Project Team

Principal Investigator Andreas Tzeremes, Student, Health and Social Care, Department
of Psychology
Supervisory Team Dr Maria Livanou, Health and Social Care, Department of
Psychology

For general queries, supply of study documentation, and collection of data, please contact:

Name: Andreas Tzeremes

Project role: Principal Investigator
Address: N/A
Tel: 00447840914836
E-mail: 22553962@stu.mmu.ac.uk
Problems relating to this study should be referred, in the first instance, to the Principal
Investigator.

Contents
1 BACKGROUND...............................................................................................................................4
2 RESEARCH QUESTION(S) AND PICO FRAMEWORK.........................................................................4
3 RESEARCH DESIGN.........................................................................................................................5
4 INFORMATION SOURCES...............................................................................................................5
4.1 Search Strategy................................................................................................................................5
4.2 Types of Study to be Included....................................................................................................6
4.3 Exclusion Criteria.............................................................................................................................6
5 STUDY SCREENING.........................................................................................................................6
6 DATA EXTRACTION........................................................................................................................6
7 QUALITY APPRAISAL......................................................................................................................7
8 DATA MANAGEMENT....................................................................................................................7

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 8.1 Data Handling..............................................................................................................................7
8.2 Access to Data........................................................................................................................8
8.3 Record Keeping......................................................................................................................8
9 REGULATORY ISSUES.....................................................................................................................8
9.2 Ethics Approval......................................................................................................................8
9.3 Insurance...............................................................................................................................8
9.4 Health and Safety...................................................................................................................8
9.5 Conflicting Interests or Competing Roles...............................................................................8
9.6 Monitoring, Audit & Inspections............................................................................................8
9.7 Protocol Compliance and Amendments................................................................................8
9.8 Data Protection and Confidentiality.......................................................................................9
10 DISSEMINATION POLICY............................................................................................................9
11 PROJECT TIMELINE.....................................................................................................................9
12 REFERENCES...............................................................................................................................9

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1 BACKGROUND

While the clinical effectiveness of individual therapeutic interventions has been

thoroughly studied in literature, group psychotherapy only gained recognition as a specialty
by the American Psychological Association in 2018 despite its first appearance in clinical
settings during the early 20th century (Ezhumalai et al., 2018). Research suggests little to no
difference between individual and group therapy in terms of clinical outcomes with a
number of meta-analytic studies of Randomized Controlled Trials supporting its
effectiveness in a number of different mental health conditions including anxiety and eating
disorders, depression, bipolar disorder and schizophrenia (Rosendahl et al., 2021).

On another note, the exponential growth of technological advancements in digital

information and communication, and the widespread internet use during the last two
decades have increasingly familiarized society with the use of technology for a wide use
range, including mental healthcare. Especially during the pandemic outbreak, the need for
teletherapy rised dramatically due to an increase of mental health disorders (Brooks et al.,
2020) and the domestic movement restrictions applied at the time which affected in-person
psychotherapy. Online and digital therapy delivery is relatively novel, and thus far
literature suggests that digital and video-conference therapy (VCP) is considered more or
less clinically equivalent to face-to-face delivery in terms of clinical outcomes (Norwood et
al., 2017) and therapeutic alliance (Cataldo et al., 2020).

The pandemic outbreak forced swift clinical changes in the therapeutic context, which
highlighted the necessity of the adaptation of therapeutic modalities to online delivery.
Research has shown that all therapeutic approaches are efficient when delivered remotely
(Dennis et al., 2020) and adapting strategies to implement a given approach to online
delivery exist in all of them (Swartz, 2020). While a number of systematic reviews and meta-
analyses regarding the effectiveness of VCP has been studied in relevance to individual
therapeutic approaches, a comprehensive and thorough systematic review regarding the
clinical effectiveness of group teletherapy after the outbreak of COVID-19 is absent from the
present literature.

The novelty of research in both group therapy and VCP highlights the necessity of the
conduction of a systematic literature review that summarizes findings around the
effectiveness of online delivered group therapy, especially after the abrupt shift of clinicians
to online delivery during and after the pandemic breakout.

2 RESEARCH QUESTION(S) AND PICO FRAMEWORK

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 The aim of this systematic review is to examine the effectiveness of group therapy
delivered remotely by answering the following research questions:

1) Is group teletherapy overall effective? Especially in the comparison of treatment- no

treatment or placebo-controlled conditions it is possible to detect the overall
effectiveness of group teletherapy in regards to its therapeutic outcomes.
2) Is group teletherapy inferior to face-to-face group therapy in terms of clinical
outcomes? When the comparison is made within the same method of intervention
(i.e. group CBT online compared to group CBT in-person) by measuring pre-post
treatment reports and follow-ups we can examine whether online delivery is
equivalent to in-person delivery in terms of therapeutic quality.
3) Is group cohesion and therapeutic alliance inferior to their counterparts in face-to-
face delivery? Group cohesion (between members) and therapeutic alliance (group
member- group leader) has been shown to have a significant impact on therapeutic
quality and outcome of the intervention irrespective of the theoretical orientation
(Burlingame et al., 2018; Cameron et al., 2021). It is therefore essential to examine
whether these two determining factors are affected by the means of therapeutic
delivery, in order to evaluate the effectiveness of group teletherapy.

3 RESEARCH DESIGN

This study is a systematic review of the literature, utilized and reported in accordance
with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)
checklist to ensure transparency, comprehensiveness, and reproducibility.

4 INFORMATION SOURCES

Using EBSCOhost Research database, the author will conduct a search using AMED,
CINAHL, MEDLINE, APA PsycArticles, and APA PsycInfo.

4.1 Search Strategy

The above databases will be searched from inception to 2023 using the following
terms:

(("psychotherapy group*") OR ("group therapy") OR ("group cbt") OR ("group

psychoeducation") OR ("psychoeducation group*") OR ("leaderless group*") OR
("therapeutic group*") OR ("group psychotherapy")) AND ((effectiv*) OR (effic*) OR
(outcome*) OR (relationship) OR (cohes*) OR (alliance)) AND ((online) OR (remote) OR

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(telepsychotherapy) OR (digital) OR (e-therapy) OR (cyber*) OR (teletherapy) OR ("web
conferenc*") OR ("video conferenc*") OR (telecare) OR (e-health) OR (m-health)). Additional
sources from the reference lists of the generated papers will also be screened. The principal
investigator will carry out the research.

4.1 Types of Study to be Included

No restrictions will be applied in gender, ethnicity and age. Due to the novelty of the
research area especially in the field of teletherapy, research design and quality will not
be considered as inclusion criteria as it risks exclusion of relevant research in the field at
the present moment.

Eligible studies will include interventions through group teletherapy, will be

quantitative in nature including but not limited to RCTs, Clustered Randomized Trials,
Clinical Trials, Cohort studies, Pilot studies, Quasi-experiments etc., and will report any
or all of the following:

 Comparisons of therapeutic outcomes based on delivery method (online vs

in-person),
 Intervention vs no intervention designs (control groups),
 Family therapy
 Reports of quantitative effectiveness measures of group teletherapy by
patients, clinicians, family, friends or community members related to the
patients

4.3 Exclusion Criteria

Systematic reviews, meta-analyses and literature reviews will be excluded from the
search, as well as studies of qualitative nature. All papers that will be reviewed will be in the
English language, studies in all other languages are excluded.

5 STUDY SCREENING

The primary author will screen title and abstract results according to the inclusion
criteria. As a second step of the process, full texts of the relevant papers will be also
screened and a PRISMA flow diagram will be used to track the screening process.

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6 DATA EXTRACTION

Data extraction will include:

 Year of publication
 Research design,
 Details of the platform(s) used
 Sample size and demographics
 Group intervention type details
 Group size
 Number and time duration of sessions
 Therapeutic outcome results (effect sizes, p-values and confidence intervals)
 Statistical comparison between online and in-person group therapy
 Follow-up data
 Number and reasons of dropouts
 Diagnostic heterogeneity of the groups
 Measures of perceived therapeutic alliance
 Measures of perceived group cohesion

7 QUALITY APPRAISAL

This systematic literature review will cover various quantitative research methods, and
as such, the Effective Public Health Practice Project Quality Assessment Tool for Quantitative
Studies, created by the Effective Public Health Practice Project (2009), will be employed. The
Quality Assessment Tool employs multiple criteria, in addition to the input of the researcher
to arrive at a scientific conclusion. After the evaluation is completed, each analysed study is
assigned a score based on eight categories: Study design, Analysis, Withdrawals and
dropouts, Data collection practices, Selection bias, Invention integrity, Blinding and
Confounders. The assigned score for each category can fall into one of three: "strong,"
"moderate," or "weak”, and the method which is used to assign score to a specific given
category is indicated in the Quality Assessment Tool for Quantitative Studies Dictionary
(Effective Public Health Practice Project, 2009). For example, in the Design category a study
will be scored as “strong” if it was described as a Randomized controlled trial or Controlled
clinical trial, “moderate” if described as a cohort analytic study, a case control study, a
cohort design, or an interrupted time series, and “weak” if any other method was used or
the method used was not stated.

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8 DATA MANAGEMENT

8.1 Data Handling

Data will be stored and analysed on the Principal Investigator’s personal computer and
data will be stored on the MMU One Drive. The project team is responsible for data entry,
quality and the analysis.

8.2 Access to Data

Only the PI and their supervisor will have access to the data. Besides them, authorised
representatives from MMU will be authorised to access the data to permit study-related
monitoring, audits and inspections. Data will only be shared with other researchers if it has
been completely anonymised and in agreement with the PI’s supervisor.

8.3 Record Keeping

Data will be stored until completion and submission of the project and destroyed using
appropriate means thereafter (paper-based data will be shredded, and data stored on the
computer will be permanently deleted).

9 REGULATORY ISSUES
9.1 Ethics Approval
Ethical approval will not be required, but the study will be registered with MMU through
EthOS. Insurance

This project will be conducted in line with the MMU Safe Working Practices guidance and
will therefore be covered under MMU Indemnity Insurance.

9.2 Health and Safety

‘There are no health and safety risks to the project team’.

9.3 Conflicting Interests or Competing Roles

None.

9.4 Monitoring, Audit & Inspections

Besides the project team, access will be granted to authorised representatives from the
University to permit study-related monitoring, audits and inspections.

9.5 Protocol Compliance and Amendments

No protocol deviation will occur without an approved amendment, discussed with the
supervisor.

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9.6 Data Protection and Confidentiality
Manchester Metropolitan University is the Data Controller in respect of this project and any
personal data that participants provide. The principal investigator and academic supervisor
are the data custodian and will handle the data in line with GDPR. In line with this, no
personal data will be shared in any way with a third party.

In case of data breach the PI will inform the their supervisor immediately who will contact
the MMU data protection team within 72 hours (legal@mmuu.ac.uk or 0161 247 3331) and
will keep an electronic record of any incident that occurred.

10 DISSEMINATION POLICY
The final project report will be available directly from the project team via email. The project
report will be submitted for a MSc dissertation.

11 PROJECT TIMELINE

 February 2023: Registration of review through EthOS

 March 2023: Literature searching
 April-July 2023: Paper screening and quality appraisal
 July-August 2023: Paper screening and quality appraisal
 August-September 2023: Writing of reports for final submission

12 REFERENCES

Alldredge, C. T., Burlingame, G. M., Yang, C. and Rosendahl, J. (2021) ‘Alliance in group
therapy: A meta-analysis.’ Group Dynamics: Theory, Research, and Practice, 25(1) pp. 13–
28.

Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N. and
Rubin, G. J. (2020) ‘The Psychological Impact of Quarantine and How to Reduce it: Rapid
Review of the Evidence.’ The Lancet, 395(10227) pp. 912–920.

Burlingame, G. M., McClendon, D. T. and Yang, C. (2018) ‘Cohesion in group therapy: A

meta-analysis.’ Psychotherapy, 55(4) pp. 384–398.

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Cataldo, F., Chang, S., Mendoza, A. and Buchanan, G. (2020) ‘A perspective on Client-
Psychologist Relationships in Videoconferencing Psychotherapy: A Literature Review
(Preprint).’ JMIR Mental Health, 8(2).

Dennis, C.-L., Grigoriadis, S., Zupancic, J., Kiss, A. and Ravitz, P. (2020) ‘Telephone-based
nurse-delivered interpersonal psychotherapy for postpartum depression: nationwide
randomised controlled trial.’ The British Journal of Psychiatry: The Journal of Mental
Science, 216(4) pp. 1–8.

Effective Public Health Practice Project. (2009) Effective Public Health Practice Project
Quality Assessment Tool for Quantitative Studies. Unknown place of publication: Effective
Public Healthcare Panacea Project. [Online] [Accessed on the 20th February 2023]
https://www.ephpp.ca/PDF/Quality%20Assessment%20Tool_2010_2.pdf

Effective Public Health Practice Project. (2009) Quality Assessment Tool for Quantitative
Studies Dictionary. Unknown place of publication: Effective Public Healthcare Panacea
Project. [Online] [Accessed on the 20th February 2023]
https://www.ephpp.ca/PDF/QADictionary_Dec2009.pdf

Ezhumalai, S., Muralidhar, D., Dhanasekarapandian, R. and Nikketha, B. S. (2018) ‘Group

interventions.’ Indian journal of psychiatry. Medknow Publications & Media Pvt Ltd,
60(Suppl 4) pp. S514–S521.

Norwood, C., Moghaddam, N. G., Malins, S. and Sabin‐Farrell, R. (2018) ‘Working alliance
and outcome effectiveness in videoconferencing psychotherapy: A systematic review and
noninferiority meta‐analysis.’ Clinical Psychology & Psychotherapy, 25(6) pp. 797–808.

Rosendahl, J., Alldredge, C. T., Burlingame, G. M. and Strauss, B. (2021) ‘Recent

Developments in Group Psychotherapy Research.’ American Journal of Psychotherapy,
March, p. appi.psychother.

Swartz, H. A. (2020) ‘The Role of Psychotherapy During the COVID-19 Pandemic.’

American Journal of Psychotherapy, 73(2) pp. 41–42.

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