Group Cohesion and Necessary Adaptations in Online Hearing Voices Peer Support Groups:Qualitative Study With Group Facilitators

Background: Face-to-face hearing voices peer support groups (HVGs), a survivor-led initiative that enables individuals whohear voices to engage with the support of peers, have a long-standing history in community settings. HVGs are premised on thenotion that forming authentic, mutual relationships enables the exploration of one's voice hearing experiences and, in turn, reducessubjective distress. As such, group cohesion is assumed to be a central mechanism of change in HVGs. The rise of digital mentalhealth support, coupled with the COVID-19 pandemic, has resulted in many HVGs adapting to online delivery. However, to dateno studies have examined the implementation of these online groups and the adaptations necessary to foster cohesion. Objective: This study aims to understand the experience of group cohesion among HVG facilitators in online groups comparedwith face-to-face groups. Specifically, we examined the ways in which the medium through which groups run (online or face-to-face)impacts group cohesion and how facilitators adapted HVGs to foster group cohesion online. Methods: Semistructured qualitative interviews were conducted with 11 facilitators with varied experience of facilitating onlineand face-to-face HVGs. Data were analyzed using reflexive thematic analysis. Results: The findings are organized into 3 themes and associated subthemes: nonverbal challenges to cohesion (lack ofdifferentiation, transitional space, inability to see the whole picture, and expressions of empathy); discursive challenges to cohesion(topic-based conversationand depth of disclosure); and necessary adaptations for online groups (fostering shared experienceandusing the unique context to demonstrate investment in others). Despite challenges in both the setting and content of online groups,facilitators felt that group cohesion was still possible to achieve online but that it had to be facilitated intentionally. Conclusions: This study is the first to specifically investigate group cohesion in online HVGs. Participants noted numerouschallenges to group cohesion when adapting groups to run online, including the unnaturally linear narrative flow of dialogue inonline settings; lack of transitional spaces, and associated small talk before and after the session; ease of disengagement online;inhibited sharing; and absence of shared physical presence online. Although these challenges were significant, facilitatorsnevertheless emphasized that the benefits provided by the accessibility of online groups outweighed these challenges. Necessaryadaptations for cultivating group cohesion online are outlined and include capitalizing on moments of humor and spontaneity,using group activities, encouraging information sharing between participants using the chat and screen-sharing features, and usingobjects from participants'environments to gain deeper insight into their subjective worlds.