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Burlingame, G.M. & Strauss, B. (2021). Efficacy of small group treatments: Foundations for evidence-based practice. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 17.

Group therapy involves one or more therapists treating more than two individuals together in a group setting. Ideally, group therapy not only includes specific individualized interventions of a theoretical orientation (cognitive restructuring, behavioral activation, transference interpretations) but also makes use of group-specific factors known to predict patient outcomes (development of group cohesion, social learning, peer feedback). In this chapter, Burlingame and Strauss report on the efficacy of group therapy for a number of disorders and relative to individual therapy. In a meta-analysis of 68 studies for a variety of disorders and different theoretical orientations, there was no difference between individual therapy and group therapy in terms of primary symptom outcomes (g = -0.03). One of the challenges of practicing group therapy is that some patients and providers might perceive group therapy as less effective or less desirable than individual therapy. However, meta-analyses of patient acceptance of treatment (percent of patients assigned to group or individual therapy and who follow through with treatment) or of patient drop out after starting treatment shows no difference between individual and group therapy. Regarding outcomes for specific disorders, over 11 meta-analyses have been published in the past decade as part of an international effort to document the effects of group therapy. For major depressive disorder, group therapy was more effective than treatment as usual (g = 0.69) and as effective as pharmacotherapy (g = 0.08). Group therapy was more effective than no treatment for social anxiety disorder (g = 0.84), panic disorder (g = 1.08), OCD (g = 0.97), eating disorders (g = 0.79), substance use disorder (g = 0.28), and PTSD (g = 0.70). For all these disorders, group therapy was as effective as another active treatment to which it was compared (individual therapy or pharmacotherapy).

Practice Implications

Patients and practitioners may have concerns about group therapy (that it is not private, that the time is divided among several patients, that outcomes may not be as good as individual therapy). Clinicians are advised to take these concerns seriously and to respond to them with an explanation based on the research – that is, that group therapy: is as effective as individual therapy, is probably more cost efficient than individual therapy, and is as well tolerated as individual therapy. Many group therapists use pre-group preparation of patients to help them understand the utility of group therapy. Referral sources may need to be educated about the accumulating research on the efficacy of group therapy. This seems particularly important as clinics, hospitals, private practices, and community agencies grapple with fewer resources to provide adequate care. Group therapy, when done well by clinicians who are adequately trained in group interventions may be a means of increasing accessibility to care for many.

Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847

For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.

Practice Implications

The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.

Author email: Simone.Jennissen@med.uni-heidelberg.de

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 (6^thed.), 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.

Practice Implications

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.