Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from thenHandbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.
Burlingame, G.M., Strauss, B., & Joyce, A.S. (2013). Change mechanisms and effectiveness of small group treatments. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6thed.), pp. 640-689. Hoboken, N.J.: Wiley.
Group treatments are the most common types of interventions offered in community, organizational, institutional, and hospital settings. They occur in many contexts including: outpatients, inpatients, day hospital, private practice, community health, support groups, drop-in centres, and educational organizations. Despite the extent of their application, group treatments receive relatively little research attention compared to individual psychotherapy or medication interventions. (Not to mention the pervasive and mistaken notion that group therapy is like doing individual therapy with 8-10 patients at once, or that individual therapy training is sufficient to be expert in group therapy). There are many reasons for this relatively lower amount of research, including the lack of expertise in and understanding of group practice among clinical researchers, and the substantially greater difficulty in running a clinical trial of group therapy (of the latter I have ample experience and war wounds). Nevertheless, Burlingame and colleagues summarized more than 250 studies that estimated the efficacy or effectiveness of group therapy for 12 disorders or populations. The findings indicate good or excellent evidence for the efficacy of group treatments for many disorders or patient groups (e.g., panic, social phobia, OCD, eating disorders, substance abuse, trauma related disorders, coping with breast cancer, schizophrenia, and personality disorders). There are also promising results for other disorders (e.g., mood, pain, and inpatients). Although there are substantially more studies on group CBT, most studies that compare different models (including IPT, psychodynamic, DBT, etc.) often produce equivalent outcomes. There is also lots of evidence that group therapy is as effective as individual therapy or medications for most disorders. In one U.S. study on panic disorder, group psychotherapy was the most cost effective (i.e., cost per rate of improvement) of the interventions ($246) compared to individual therapy ($565) and medications ($447). There is also research on the effects of specific characteristics of groups. For example, research on group composition (i.e., heterogenous vs homogeneous in terms of patient population or functioning) has produced mixed results, though there is emerging evidence that heterogeneous groups tend to benefit those who are lower functioning. Further, research on group cohesion (i.e., the bond between the individual and the group) which is a construct related to but distinct from alliance, is positively associated with treatment outcomes with a moderate effect size.
Group treatments are as effective as individual therapy or medications, and are likely more cost effective. However group therapy is more complicated to practice and to study. Burlingame and colleagues suggest using empirically validated interventions, and ongoing assessment of client outcomes. They also suggest following the American Group Psychotherapy Association (AGPA) practice guidelines (see the Resources page on our web site), that include best practices for creating a successful group, appropriately selecting clients, preparing clients for group, evidence based interventions, and ethics issues related to group practice. Finally, Burlingame and colleagues emphasize using AGPA recommended measures and resources in developing and assessing a therapy group. These include: (1) group selection and group preparation which may involve handouts for group leaders and members about what to expect and how to get the most from group therapy; (2) assessing group processes repeatedly during group therapy using measures like the Therapeutic Factors Inventory or the Working Alliance Inventory; and (3) measuring client outcomes by using an instrument like the Outcome Questionnaire-45. Repeated measurement and feedback of processes and outcomes to the therapist may improve the group’s effectiveness.