A STUDY OF ATTITUDES ABOUT
INDIVIDUAL AND GROUP THERAPY
IN CLINICAL AND NON-CLINICAL POPULATIONS

by

Jure Biechonski MSc Counselling - Psychology

Submitted in partial fulfilment of the requirements for the degree of Master of Science

The Roehampton Institute of Higher Education

Department of Psychology

University of Surrey

September 1994

ABSTRACT

The purpose of this study was to obtain a better understanding of the nature of attitudes and perceptions about individual and group therapy, and suggests guidelines for referral to individual or group therapy. The study investigated those attitudes and perception among four groups of subjects. a) Those who had individual therapy experience, b) those who had individual and group therapy experience, c) those who had group therapy experience, d) those who did not have any therapy experience.

Eighty-one individuals completed a questionnaire, designed specifically for the study. The questionnaire contained 30 positive and negative statements about individual and group therapy, each requiring the participant to report on a 4-point, agree-disagree format.

The results of the study reflected that: (1) Subjects that had individual therapy experience had the most favourable attitude towards group therapy, while subjects that had no therapy experience had the most negative attitude towards group therapy. (2) Subjects that had group therapy experience did not favour any therapy at all. (3) Subjects that had individual and group therapy experience could value more both therapies.

Possible explanations for these results were the natural development of human beings by starting their first bond with one parent before integrating into society. Another explanation to the negative attitudes towards group therapy was due to the negative portrayal of group therapy.

Recommendations were offered that therapy should start on an individual basis. As a client needs to re-establish primal parental bond.

Recommendations were also offered concerning the use of a survey checking clients' attitudes prior to referring them to individual or group therapy, in order to tailor the prospective client’s personality, expectations and perceptions to a suitable therapy programme.

LITERATURE REVIEW

Psychotherapy is an intricate blend of art and science, (Bloch 1982).

Without the art, the therapist is reduced to a mere technician, the client to an object for manipulation. Without the science, the therapist is subject to the current fashion or bound inflexibly to his/her preferred belief system.

Therapy is an inclusive label for all manners and forms of treatment of disease and disorder. The aim of therapy is generally considered to be personality change of some sort. Let us use counselling to refer to a helping process, the aim of which is not to change the person but to enable him or her to utilise the resources he! she now has for coping with life.

Therapy exists in two major forms - individual therapy and group therapy.

Just as it is not appropriate to speak of a single therapy regarding individual therapy, it is not appropriate to speak of group therapy in the singular form, but of group therapies that differ in size, membership and purpose.

The word therapy suggests that what is involved is treatment of patients by health care professionals. While approaches such as person-centered, gestalt and psychodrama tend to see their members as clients or simply as people, leaders of behavioral-cognitive groups will see themselves as educators

Even the experiences in these groups tend not to be therapy but often may be therapeutic. The word group presents too, some difficulties in definition.

Technically when two or more people come together a group is formed. Group therapy occurs when those people interact and influence each other to a therapeutic end. (Shaw 1976).

A tradition of conducting research into group therapy exists, specially over the last 25 years. (Dies 1979; Frank 1975). Most research has focused on two main areas: process and outcome.

Focusing on those two areas does not take into consideration the clients’ needs, to check what those needs are; I would like to focus on what precedes the process, the clients’ expectations and perceptions of individual and group therapies. Understanding the perceptions and the expectations might influence the process that might influence the outcome.

Bion (1961) defines group therapy in two terms:

*The treatment of a number of individuals assembled for special therapeutic sessions.

*A planned endeavor to develop, in a group, the forces that lead to smoothly running co-operative activity.

Rogers (1951 p.278) claims that in significant respects, group therapy is like individual therapy. It is also distinctively different. The similarities arise from a common purpose and from shared conception of the nature of human personality and how it changes. The differences arise from the important fact that in individual therapy only two people are immediately involved whereas in group therapy five or six or more persons interact in the process of therapy. This multiplication of the number of the participants means more than the extension of individual therapy to several persons at once; it provides a qualitatively different experience with unique therapeutic personalities.

Dryden (1988) has stated that we are all part of a group, we are born into a family, study at school, work. We are in a permanent interaction with others. The problems that our clients present us with, are between them and themselves that affect their interaction between them and others, or between them and others that influence their interaction between them and themselves.

Human beings are born in groups, live in groups and die in groups. Without the support and co-operation of others, individual efforts count for little or are unsuitable. Attitudes and social behaviour are learnt from interaction and are expressed in interaction. It is in interaction that many of the sources of personal emotional satisfaction and growth are to be found (Aveline & Dryden. 1988)

According to Rogers (1951 p.289) it seems increasingly clear that the discrepancies in the perception of self, which are the source of the discomfort that brings a person to therapy, are products largely of the experiences the individual has had with a relatively few persons who have been important in his/her life.

Jung (1950) was critical of group therapy on the grounds that the tendency in any group was to lower the level of consciousness and thus act against the individuation process on which he laid so much stress. Therapy, Jung maintained logically, was essentially individual in its very nature. (Fordham 1986)

Fiumara (1976) has considered the possibility that group therapy may complement individual therapy by acting as a 'testing ground for individuation'. Group therapy is therefore seen as a complement to rather than an opponent of individual therapy.

It is the end-phase of group therapy that displays its limitations most conspicuously. Each group member who exhibits separation anxiety, depressive emotions, and multiform idiosyncratic fantasies because of the momentous impact of the group's impending dissolution will have much less time for consideration of termination than would be his/her lot in prolonged individual analysis.

Individual and group therapy have existed separately, different theorists have argued about the advantages of one over the other, some attempts of comparing both therapies where made.

The question to be asked now is ‘what about combining the two therapies together and running them concurrently?'

The integration of the two techniques requires careful consideration of the sequential or simultaneous involvement of the two modalities, and also of the possibility that no general conclusion in this respect will fit each and every case.

Freud (1921) commented that the character of the group is highly dependent on the character of its leader, who par excellence the figure onto which the super-egos of group members are projected.

The individual is also faced in the group with the impressive power of numbers. Narcissistic defenses are often more easily challenged within a group, and more enduring and far reaching modifications of the superego are more quickly achieved.

Freud explicitly denied any dichotomy between individual and group psychology,

'each individual is a component part of numerous groups, he is bound by ties of identifications in many directions, and he has built up his ego ideal upon the most various models' (Freud 1955, p.101)

On the other hand Bion (1959) sees the group as an entity, rather than individual clients the group is a focus of study and therapy. The therapist's task resided essentially in confronting the group with its powerful unconscious striving and offering appropriate interpretations that were expected to lead to insight and improved behaviour (p.127)

While many different combinations of group and individual therapy may be practiced, no systematic data permit firm conclusions about the effectiveness of any of them. (Yalom 1970 p.413.) Guide-lines must be formulated from clinical judgment and from deductive reasoning based on the posited therapeutic factors.

In Yalom's clinical experience, he claims that concurrent individual therapy is neither necessary nor helpful except in certain instances. Occasionally individual therapy is required in order to enable the patient to use the group: a patient may be so fragile or blocked by anxiety or fearful of aggression as to be unable to participate effectively in the group therapeutic process. In other cases, according to Yalom, it is helpful to supplement ongoing individual therapy with group therapy.

For example, some clients in individual therapy are arid and unable to produce the material necessary for productive work. (P.415) Other clients may improve in behaviour in the individual therapy hour yet be unable to transfer the learning to outside life that's why the group setting may serve as a valuable way station permitting clients to experiment with new behaviour in a protected low-risk environment, and then to transfer it to the outside life. The group setting may serve as a valuable way station permitting clients to experiment with new behaviour in a protected low-risk environment. New material may be generated with the disconfirmation of a client’s fantasies of the calamitous consequences that might follow new behavior, and gradually that the client becomes able to transfer to outside life what he/ she has learned.

Sometimes in individual therapy severe unreconcilable problems in the transference and countertransference arise; the therapy group may be particularly helpful in diluting transference and facilitating reality testing.

Concurrent individual therapy can also complicate group therapy. When the two therapists work in a different approach they might work at cross-purpose. The client may judge one approach on the basis of the other and feel frustrated and discouraged by the initial group meeting that offers less support then their individual therapy hours, where their narcissistic needs are gratified by the therapist's exclusive attention.

Clients may use their individual therapy to drain off effect from the group. The client may remain passive during the group session relying on his/hers private hour.

In this case it is recommended that either the group or the individual therapy be terminated.

The individual and the group therapeutic approaches may complement each other when the individual and group therapist are in frequent communication and the clients are aware that they are sharing information between them.

The individual therapy must complement the group approach by being itself, here and now oriented and by devoting time to explore, in depth, clients' feelings towards the group members. (Yalom 1970 p. 416-418)

It thus becomes apparent that therapy in a group can profitably complement individual therapy, and that the opposite is true also.

Abse (in Pines 1983 p.25-27) does not favore the combined module.

This combined procedure raises the level of the primal father transference in a way that increases the difficulties of analysis, at least in my experience.(p.25)

Later on he admits that the group does help the transference symptoms to melt away. But he insists that the therapies should not be combined and one should come before the other. He suggests that ideally psychoanalysis will be followed by group analytic psychotherapy followed by further analysis.

Another problem that the combined module provides is: some therapists may become confused about confidentiality; it becomes increasingly difficult to remember who said what in which setting. The therapist may repeat in the group intimate material that was revealed in a private session. (Yalom 1970 p.417)

Yalom recommends that the therapist should retain the privilege of bringing up any material from the individual session into the group according to his/ her professional judgment. It is ill advised to make any contract of confidentiality regarding the individual sessions. (Yalom 1970 p.417)

Cohn (1986) disagrees with Yalom and stresses the importance of the confidentiality in the private session, he sees it as crucial to the individual therapy.

The combined approach also gives the therapist the opportunity to extend the observation of his or her countertransference. Seeing the patient interacting with others may help the therapist to become more aware of his her own feelings of possessiveness and jealousy. In a group the therapist is no longer the only important figure for the patient: this may enable him or her to be a truly 'good' parent and let the patient go(p.331)

In the group, sibling rivalry comes into the open, and the 'children' learn to share their 'parent' with each other, a step on the way to independence.

At time's sibling rivalry and factionalism are pronounced in a group whose members see the leader in concurrent individual therapy; some of the members who cannot afford the private therapy might resent those who do.

Oedipal concerns are resolved in the group by means of a recapitulation of the family of origin, one of the therapeutic factors described by Yalom (1970). The presence of siblings, brings home the reality of the parental leader's sexuality, and the family romance or lack of it can be reworked.

Leo Stone (1982) defines the basic practically, universal longing of humankind for an omnipotent parent figure, as a force that permeates our whole social organisation, This is apparent in some religious attitudes.

According to Dryden (1990 p. 235) some clients may initially require individual therapy when they are most distressed but can then go on to a group as their mood improves. These clients might have interpersonal issues like: lack of assertiveness or fear of disapproval. Those clients will certainly favour individual therapy over group therapy.

There are problems in trying to compare individual and group modalities. The vast differences among therapists, clients, and approaches may overshadow the differences among modalities (Hill 1990 p.126)

In the individual therapy the therapist has greater opportunity to express his or her power, expertise, and unconditional regard. In the group therapy the therapist cannot offer total and undivided attention to any particular client. The client experiences a greater risk in the group setting.

The initial work of historical tracing, elaboration, clarification, and establishment of a working alliance can be adequately accomplished only in the privacy of individual sessions. (Aronson 1979 p.11-22)

Freud (1921) in his Group Psychology and the Analysis of the Ego point out that individual and group psychology cannot be absolutely differentiated because the psychology of the individual is itself a function of the individual's relationship to another person or object.

In individual therapy, there is a focusing on how the problem developed, and an exploration and uncovering of its roots (Dryden 1988 p.36)

Foulkes (1964) contrasted the 'vertical' analysis of individual therapy with the 'horizontal' analysis of group therapy, in which the focus is on lateral communication and the here and now interactions of the group. (Dryden 1988 p. 36)

In individual therapy the working alliance is established, psychodynamic understanding is developed, and the origins of the client's behaviour can be explored in context of their unique history. Individual therapy provides a level of relatedness that is not possible in group therapy.

This proves that individual therapy should precede group therapy, individual therapy is preparing the client for the group experience, the unprepared the client might experience too many anxieties in the group situation.

Adding the group experience to the individual therapy allows the working through process to be more realised, insight to be translated into behaviour changes and the defenses to be modified. (Caligor et al. 1984 p.5)

Combined individual and group therapy, in fact, amplify the total therapy experience by providing more varied and differentiated relationships. (Caligor et al. 1984 p.5)

The format of individual therapy was found to be particularly appropriate for achieving the major therapeutic aims of the initial phases of analytic treatment:

forming a working relationship, training the client to be a client, motivating him/ her towards further explorations of his hers personality, and providing a foundation of trust and confidence which would be indispensable later on when the anxiety which attends all personality reorganization emerges (Aronson 1979 in Caligor et al. 1983 p.8)

Group therapy:

Enhances the development of a stable sense of self and encourages a more independent, self-determined relationship with the therapist. It serves to more fully complete the developmental tasks to which analytic therapy addresses itself.

Group therapy will be more effective in later phases of treatment.

Caligor (1983 p.9) claims that combining individual therapy and group therapy is not additive but complexly interactive and could cancel each other out.

Ideally, one might think that such an arrangement would be optimal; but in practice, combined therapy often leads to a lessening of the effectiveness of both methods. (Wolfe & Schwartz 1962 p.180)

S.H. Foulkes and James Anthony (1957) preferred sequential use of the two modalities to avoid the negative effects between them.

Either group therapy should follow individual as a "rounding off" process, or individual should be preceded by group as a preparatory measure. (Caligor 1983 p.9)

Foulkes (1948) was in favor on combining the two modalities but in 1964 he changed his mind saying that the complications arising from the this dual situation were overlooked. (Cohn 1986 p.327)

Clients that make substantial progress in the early stages of individual treatment later slow up, reaching impasses that do not move them to resolution. Some clients end the treatment with more limited gains than they seem to have the potential for. (Caligor 1983 p.20)

It can be due to the limitation of the treatment. This is were group therapy can move this client forward. The insight achieved in individual therapy does not necessarily flow into changes in behaviour. The individual session with sensitive listening and appreciation by the therapist who creates a safe environment for the client may not evoke the anxieties and the defenses stimulated by inattention, competition, or rivalry in everyday life (Caligor 1983 p.20)

A model of therapy that combines individual and group work leaves us with the vast number of ambiguities that psychotherapy poses, but it does increase our options. It is not offered as a solution for all the problems of therapy or for all patients (Caligor et al. 1984 p.37)

In individual therapy the therapist is regarded as the knowing authority and the client as the novice. While this structure might increase therapeutic effectiveness, it is not consistent with more adult functioning.

As Erikson (1950) said that the crucial developmental tasks that are completed in the stages of development beyond childhood.

The gradual resolution of the transference reduces the fantasies and distortions the client has about his therapist, as all-powerful but the experience that the client had till now with the therapist in the therapeutic relationship persists and is difficult to modify. The group therapy helps at this stage. It promotes further resolution of transference distortion, (Caligor 1983 p.36.).

In Group therapy, the relationship becomes less uneven and more balanced.

The group therapist tends to be informal, open, and actively engaged with patients; in individual therapy, the therapist unfortunately, tends to remain impersonal and distant. (Yalom p.418)

Social psychologists and therapists who have worked with small groups have observed that, for most people, entry into a group creates anxiety. This anxiety is related by Freud to oedipal issues the fear of the primal father, and the capitulation to him.

The regression induced on the individual by a new group suggests that the initial anxiety resonates with archaic experiences like the infant's early experience at the mother's breast. Splitting, projective identification and idealisation are more likely to take place in the group, (Bion 1961 P.128). This is why the group therapy experience as a first experience of therapy might be too anxiety provoking and can procrastinate clients from any form of therapy in the future.

By using Erickson's eight stages of man (and woman) the individual therapy can be compared with the movement of the client from mistrust to trust, moving to group therapy will be like moving from shame and doubt to autonomy, and the working through process of the therapy will be at the stages of initiative and industry, then the client will proceed to identity, create intimacy and end the therapeutic process with ego integrity.

The transition from individual therapy to group therapy can be seen metaphorically as the transition of the child from the safety of the nuclear family into society.

We believe that individual therapy and group therapy offer complementary access to the patient's dilemma, with group therapy providing a unique opportunity for gaining interpersonal awareness and individual therapy allowing unique opportunity for exploration and resolution of intrapsychic issues. Rutan & Alonso (1982)p.268

Balint (1972 p.61-65) pointed out that one of the unique stresses that groups place on members is that each person in a group must learn to come to terms with the notion of fair shares, rather than equal shares. The needy or the more powerful get more in this case, the group reflects the reality in the outside world.

Individual therapy spares the patient that dilemma, although the patient may still experience a feeling of deprivation.

In groups the potential of betrayal and humiliation takes on different aspects in individual therapy and group therapy. One or more members of a group may reject or humiliate a client, others may come to his /her support. The client is free to see the therapist in either camps.

In individual therapy the client is much more protected from humiliation at the hands of the therapist.

The group helps the client with early fears of stranger and anxiety, individual therapy helps the client with issues of object constancy and the development of basic trust and security (Rutan & Alonso 1982 p.268)

A referral to group therapy often reflects a chance, availability of services, rigid reliance upon diagnostic labels, and difficulty in the therapeutic relationship, rather than a through understanding of the client's interpersonal and intrapsychic state. (Rutan & Alonso 1982 p.270)

Breen (1977) compared:

"...a group can still function even there is a remarkable degree of splitting and patients represent denied and projected parts of each other and when the therapist is perceived as totally bad. In the individual setting, however, at least a hope in the potential goodness of the therapist must be there if the patient is to go on with the sessions" (p.504)

According to Rutan & Alonso (1982 p. 270) there are at least three instances when it is useful to add group therapy to individual therapy:

1. when insufficient associational material is available in the individual therapy,

2. when significant interpersonal issues beyond those that can be successfully resolved through the transference becomes apparent in the course of the individual therapy,

3. when a client's pathology causes especially difficult.

There are four distinctive situations in which it is useful to add individual therapy to clients who have been in group therapy only:

1. when the client is unable to share in the group over a prolonged time,

2. when the client heard a specific issue in the group and wishes to intensify the work on that issue,

3. when the client becomes too fearful to remain in the group without the assistance of another therapeutic relationship,

4. when the client suffers an externally induced real-life crisis.

In addition to those points there are also four situations when the addition of group therapy to individual therapy or of individual therapy to group therapy would not be in the service of the therapy:

1. when the addition of a therapy will be used to avoid confronting something important in the present therapy,

2. when adding a therapy can create difficulty for the client in integrating and processing conflicting data and can lead the client to become anxious and frightened,

3. when the client cannot tolerate competition from the primary object, group therapy should not be added to individual therapy,

4. when the client cannot tolerate the one-to-one intimacy, and find himself secured in the group interaction.

After discussing the different views about individual and group therapy and the possibility of combining them, I will now look into some studies that have tried to compare those therapies.

These studies have tended to produce mixed results.

Smart (1969) in his study of 1091 alcoholics, found out that the clients who showed most improvement after one year, in drinking behavior, tended to have received group rather then individual therapy. The clients with the poorest outcome were those who were exposed to a combination of the approaches (Solomon 1982 p.69-83).

In contrast McCance & McCance found that there was no difference between the various treatments given and outcome depends largely upon the individual clients and the history of their condition, (in S. Solomon 1982 p.72).

S. Solomon (1982) has found that the client's characteristics were the factor of success and the importance is to match the specific client to the specific therapy.

Furthermore, research evidence indicates that borderline patients highly value their group therapy experience - often more than their individual therapy experience. (Yalom 1970 p.408)

Border line clients cannot tolerate the intensity and the intimacy of the one to one treatment setting due to creeping transference problems both transference and countertransference invariably emerges in individual therapy.

For that reason one of the major advantages that a therapy group may have for borderline clients is that the ongoing stream of feedback and observations from the other group members is a powerful reality testing.

Group therapy is unique in providing a forum for the mutual exchange of honest, explicit feedback. By contrast feedback in individual therapy can only come from an authority figure - a radically different type of source than a patient's peer (Bloch & Crouch 1985, in Furingham & Burlingham 1990 p.44)

Individual therapy with border line clients may be marked by the absence of a therapeutic alliance. The client may be unable or unwilling to use therapy for personal change and, instead demand gratification or revenge from the therapeutic relationship, (Yalom 1970p.410).

In group therapy the client will observe the others working and pursuing concrete goals and manifesting changes often suppling an important corrective to the sole exclusive focus on extracting supplies from the therapist.

In research that studied change patterns in borderline clients in individual therapy and group therapy it was found that the group is a stronger stimulant and a more appropriate setting for eliciting pronounced changes in ego functioning.

The therapist's choice of psychotherapy must include a contiguous plan of therapeutic forces advantageous for a client in a given time. (Kretsch, 1987 p.109-111)

Slavinska (1983) suggests that a preliminary period of individual therapy is essential, with border line clients. Her conclusion is that in the case of border line clients, the homogenous group is the most effective.

It should be also said that border-line patients as a group are especially insightful, often see things the therapist does not, and can lead the therapist in new and fruitful directions. (Slavinska 1983 p.310)

The group provides the client with an opportunity to obtain greater distance from the therapist. By observing, the client is able to internalise aspects of the therapist's behaviour. By noticing the support and listening skills that the therapist applies in the group the client might incorporate the same behaviour with other group members or others' individuals in his / her life.

On the other hand, Fuhriman & Burlingame (1990) claim that although it appears that consideration of homogeneity /heterogeneity issues is critical in forming a group, what factors should be similar and what ones should be different remain empirically unanswered. (p.16)

"Comparisons of individual therapy and group therapy may be of little value, however, unless client differences are also taken into account." (S. Solomon 1982 p.70)

Piper et al. (1984) compared four forms of psychotherapy. The result of their research has indicated that long-term group therapy and short term individual therapy are more favourable and effective than long term individual therapy and short term group therapy.

In short term individual therapy the attention was concentrated and focused. Effective involvement was high. Although the range of problems explored was not extensive there was depth associated with those that were explored. Both parties, clients and therapists, felt the need to work hard and relatively quickly.

In long-term individual therapy, although the clients seemed satisfied, the therapists found that the structure and process less satisfying. The length of time available increased the resistance and decreased the working through. The clients behaved as if there was always plenty of time to work later.

In short term group therapy, both clients and therapists have experienced difficulties. There was anxiety about working on sensitive issues in the presence of others, and anxiety about ending the group. The therapists have found that using a psychoanalitically oriented approach trying to treat 7-8 clients in the same time was extremely difficult.

Long-term group therapy was favoured by both clients and therapists, the continual stimulation brought a high degree of involvement and attentiveness by both parties.

On the other hand Webster-Straton (1984), in comparing two groups of parent and children, one group in 9 week individual therapy and one group in 9 week group therapy, did not find any significant differences on any of the attituditional or behavioral measures between individual and group therapy.

Although on the one hand the individual therapy offered direct feedback elements and greater flexibility to focus on the parent's and child's unique problem, on the other hand the group serves as a powerful source of support, reinforcement and ideas.

More families have applied to individualised therapy, parents from the individual therapy are more attached to or dependent on their therapist to help them solve their specific problems, while in group therapy the therapist was more able to help parents to solve their problems independently. Parents from the group therapy were more able to turn to other parents for advice and support when a problem arose.

McMahon & Forehand 1983 (in Stratton 1984 p.667) have reported that parents are more satisfied in individual therapy then in group therapy.

Research by Stone & Rutan (in Rutan & Alonso 1982) found that of clients who had individual therapy or concurrent individual therapy, only 16% dropped out of the group within the first year compare to 50% of clients who had not any individual or concurrent individual therapy.

These figures lend support to the argument that in many cases concurrent individual therapy helps clients stay in group therapy long enough to experience some help from it. Only clients that have experienced both therapies will have the full understanding of the values that group therapy has.

Rush & Watkins (1981 p. 100-102) studied the outcome of individual therapy versus group therapy in treating depressed clients by using a cognitive approach. The results were that the efficacy of group therapy was not as great as individual therapy.

Dryden (1990 p.235) says that for these reason therapists reserve group work for the less severely disturbed client. Some problems however, lend themselves to a group approach. Social anxiety and other problems that contain a significant interpersonal element may be well suited to group therapy, since it allows a degree of in-session testing out of maladaptive beliefs about other people. Another consideration in choosing clients for group therapy is the extent to which the group can help in modeling appropriate coping behaviour .

Group therapy was not found to be significantly more effective than a delay, although group therapy subjects who suffered from mild depression tended to improve more than delayed therapy controls. (Wierzbicki & Bartlett, 1987 p.337-342)

Fenchel (1990) assumed that combined therapy offers the practitioner a rich data field for observation and research he hypothesized that different therapeutic environments evoke different level of responses. the questions he asked were:

• Can we expect different faces from patients in combined group and individual therapy?
• What makes combined therapy successful for a particular person?
• What can be learned from those patients who seem to benefit from only one modality or the other?

The results were that 4 out of 7 clients reacted differently to different therapies the other 3 reacted rigidly the same. The conclusion of this study was that it is important to check individually the adaptation and suitability of each client to a specific form of therapy.

Coolidge & Grunebaum (1964) saw the group therapy as an alternative to unsuccessful individual therapy. (Bromfield & Pfeifer 1988 p.220)

Bromfield & Pfeifer (1988) by testing a combined therapy setting with children, claim that the therapist may be confused by the 'different' child he sees in individual and group settings. The child who is typically gentle in individual sessions may become a sadistic bully when having to share his therapist with other children. (P.224)

Those mixed results about the effectiveness of various forms of therapies with different clients prove that there is no consensus about the productivity of efficiency of one form of therapy on the other.

Results of the research literature review suggest that in 75% of the studies, group treatment is as effective as individual treatment. In 25% of the studies the group treatment is more effective. In no case individual treatment was found to be more effective then group treatment, but sometimes it was found to be more efficient, (Toseland & Siporin 1986 p.171-195).

By exploring the various researches and studies, the question is asked: efficient and effective to whom and according to whom?

Rogers (1961 p.227) claims that there is a wide spread acceptance of the idea that the purpose of research in psychotherapy is to measure the degree of ‘success’ or the degree of ‘cure’ achieved. There is no general agreement as to what constitutes ‘success’ whether it is removal of symptoms, resolution of conflicts, improvement in social behaviour, or some other type of change. The concept of ‘cure’ is entirely inappropriate, since in most of these disorders we are dealing with learned behaviour, not with a disease. The question is not ‘what success was achieved?’ or ‘was the condition cured?’. Instead we have to ask a question that is scientifically much more defensible, namely, ‘what are the concomitants of therapy?’.

The research should then focus on the clients’ subjective world.

Slocum (1987) has conducted a survey of expectations about group therapy among clinical and non-clinical populations.

The results reflected three major categories of expectations:

1. Group therapy is unpredictable,

2. Group therapy is not as effective as individual therapy, and

3. Group therapy can be detrimental to participants.

These results reinforce Levine's (1979) suggestion that group therapy can help with most things that individual therapy can providing an appropriate group be available and the individual will accept the group as a mode of treatment. (p.11)

Budman et al. (1988) compared outcomes in time-limited individual and group psychotherapy. It was found that both treatments were quite beneficial, there was a clear preference by clients for the individual therapy. (p.64-101)

Raising the question of group therapy with an individual client poses potential countertransferential problems specifically because the request is for the therapist's benefit as well as for the client's benefit. (Jerome Gans 1990 p.132)

Another countertransferential attitude may occur when the therapist is not dealing properly or is unable to deal with the client's transference and dumps him /her into the group setting when the transference is easier to handle.

For the aware therapist, exploring the possibility of combined therapy leads to an enriched understanding of the state of the individual therapy; improved patient selection; an element of (role) play which enable a kind of confrontation not ordinarily available in individual therapy; and a heightened awareness of countertransference reactions. (Jerome Gans 1990 p.136)

Understanding the differences between individual and group therapy and comparing between them in view of research and theory is not more important then understanding the perceptions that the potential clients have regarding those therapies. Because of the dropouts from group therapy specially from clients that did not have any previous therapy there is a danger that those clients will not return to therapy.

According to Hill (1990) an unfair advantage was given to group therapy research, she claims that most factors that are regarded to apply to group therapy can also be applied in individual therapy.

By comparing individual therapy to group therapy and to combined therapy, we have to check the effectiveness of those modalities. But the question is: Is it possible to measure the effectiveness of therapy?

Eysenck (1985) in his article 'The Battle Over Therapeutic Effectiveness' protects his thesis from 1952 that shows that there is no evidence to prove any improvement in patients due to psychotherapy (Hariman 1985, Chapter 5)

He is calling for further research involving the scientific psychology to take part in further research because no evidence is found to prove the efficacy of psychotherapy.

We know that psychotherapy works, we do not clearly understand how it works (Stiles 1986 p.175)

All research so far has worked on process versus outcome further research is needed to understand how people adjust and grow. The paradox that all therapies do not show meaningful differences is due in my opinion to the fact that research is based on the wrong assumption, there is so much that we still do not understand in human behaviour that the tools that we are producing to measure it prove themselves insufficient.

Is psychotherapy effective? is considered to be a poor question and, consequently, can only receive poor answers. (Garfirld 1980 p. 283)

Psychotherapy is not some clearly defined and uniform process. The fact that practitioners follow certain school of thought and use certain techniques appears to be a matter of faith and personal judgment. There is no basis for any objective judgment on the outcome of psychotherapy. Therapists from the same school might perform differently, with different types of clients, with different types of problems.

The main problem is not the research but the question asked. The question should be: What type of therapeutic procedures will work best with clients with given types of problems administered by what kind of therapist? (Garfield 1980 p. 284)

Is it individual or group therapy or both?

contd.....