Yes, And… A Reconsideration of Concurrent Individual and Group Therapy to Improve Outcomes
Erika M. Pelzer
Doctoral Student
Professional Psychology Department, The George Washington University
Yes, And… A Reconsideration of Concurrent Individual and Group Therapy to Improve Outcomes
Erika M. Pelzer
Doctoral Student
Professional Psychology Department, The George Washington University
It is well known that group therapy is an effective form of therapy especially when performed by clinicians who follow evidenced-based group processes (Burlingame et al., 2012). Treatment response to group therapy is comparable to individual therapy in a natural setting (Burlingame et al., 2016) and it is common practice for clinicians to offer group and individual therapy at the same time. Discourse about how best to combine therapies have been ongoing, and as early as 1947 (Bernard et al., 2008; Burlingame et al., 2024; Lipsius, 1991; Sager, 1960; Shaskan, 1960; Wender & Stein, 1949). However, efficacy research is mixed when combining group and individual therapy at the same time (Burlingame et al., 2016; Crits-Christoph et al., 1999; Panas et al., 2003; Weinstein et al., 1997). As a new doctoral student, I was surprised by these findings and chose to investigate it further. The aim of this paper is to briefly review key research and offer humble suggestions for further considerations.
The effectiveness of individual, group, and conjoint psychotherapy was compared by Burlingame et al. (2016). Conjoint therapy, in the context of concurrent individual and group therapy, is when the therapist leading individual therapy is not the same therapist as the one leading group therapy (Porter, 1993). In contrast, when the same therapist leads both settings, it is often called combined therapy (Smolar, 2018), although the term is not used consistently. Burlingame et al. (2016) concluded that group therapy was deemed just as effective as individual therapy. However, the authors reported that additional group sessions (six more group than individual sessions) were required to meet the same outcome as individual therapy alone. Resource efficiency was also considered, and even though more group sessions were required, the client-to-patient ratio was 60% less than in individual therapy, concluding group therapy is effective and efficient. Burlingame et al. also found that conjoint therapy appeared to be effective and better than individual therapy alone when considering absolute rates of change, but not as effective as individual or group therapy when using trajectory of change, which is perplexing. In addition, conjoint therapy resulted in two to three times more therapist time than group or individual therapy alone, respectively. This is not surprising, given the high ratio of individual-to-group sessions (5:4) reported in the conjoint therapy group. In addition, over the 27-weeks in treatment, on average patients attended therapy for only 11.5 weeks, indicating the frequency of therapy was no more than once every two weeks and not consistent intervals across all samples.
Erekson et al. (2015) wrote a compelling paper investigating the impact of psychotherapy session frequency on dose response in a natural setting. The dose-response model is a way to estimate therapeutic benefit by the number of doses (i.e., sessions) received (Howard et al., 1986). The results of the Erekson et al. paper indicate weekly sessions produce improved outcomes in the shortest amount of time and experience less deterioration. Another study (Cuijpers et al., 2013) reported that two sessions per week were more effective than one in treating adult depression. In addition, Cujpers et al. reported a small negative correlation between effect and weeks-in-session, suggesting more sessions in a shorter amount of time may be ideal in acute settings.
Interestingly, Davies et al. (2008), using the same clinic sample as the Burlingame (2016) study, found that clients who received conjoint therapy perceived less engagement and cohesiveness in their group sessions compared to clients in group therapy alone. It was Davies et al. who opined that individual therapy might lessen the importance of group work when combined. However, the study reports the average number of group sessions attended was six (mode = 2), which may not have been enough sessions to create cohesion and engagement in this sample.
Where to go from here? Based on the literature reviewed, I offer the following paths for further research. First, it would be informative to consider how the ratio of individual-to-group sessions impact effectiveness of combined and conjoint therapy. By lowering the ratio of individual-to-group sessions significantly (e.g., 1:1, 1:4, 1:6), clients must rely heavier on group therapy dynamics, and less frequently on the dyad, which may facilitate engagement and cohesion within the group while still offering the benefits of individual therapy. Group sessions would thus become the primary relationship instead of the dyad. As an added benefit, lower ratio would improve resource efficiencies.
The literature would also benefit from further exploration of session frequency (once per week or more) and concentration of sessions within a relatively short time period, to expand on findings from Cuijpers et al. (2013) and Erekson et al. (2015).
Yet another area to investigate is the impact of utilizing the same therapist for individual and group sessions, versus a different therapist for each modality (i.e., combined vs conjoint). Lipsius (1991) indirectly emphasized the importance of controlling for the same therapist across settings to ensure transference and resistance is addressed in the modality of origin – encouraging group engagement and cohesion. By utilizing the same therapist across both settings, inter-modality insights and resistances can be bridged resulting in an integrated modality that “is at least as great as the sum of the parts” (Lipsius, 1991, p. 326). I believe this factor alone could contribute to better therapeutic outcomes. Howbeit, utilizing the same therapist in both settings can present practical complexities, as not all therapists offer both individual and group therapy. In addition, conjoint therapy has therapeutic advantages (see Porter, 1993 for more detail). To maximize therapeutic outcomes, both Porter (1993) and Bernard et al. (2008) stress the importance of open communication between therapists when offering conjoint therapy. It would be informative if future studies were to track the level of communication between therapists when assessing the effectiveness of conjoint therapy.
Lastly, it would be worth considering in more detail which populations may uniquely benefit from concurrent individual and group therapy (whether combined or conjoint). Because concurrent therapy allows for transference, both in a dyad and group setting, more severe indications may particularly benefit. For example, patients with severe trauma, social anxiety, or severe symptomatology in general may benefit from concurrent therapy as they are able to improve interpersonal skills in a group setting and yet explore issues in individual therapy for which they are reluctant to initially explore in group (Lipsius, 1991; Phillips, 2009). A preliminary study by Dickhaut and Arntz (2014) also supports this claim. The authors found concurrent therapy to be effective in decreasing symptomology and increasing normative range of happiness in outpatients with severe borderline personality disorder.
This paper is by no means an exhaustive literature review. However, it is apparent more research in a natural setting is warranted to fully explore outcomes of concurrent individual and group therapy. The suggestions outlined above consider factors that may have obscured the effectiveness and efficiency of combined and conjoint therapy in past studies. For now, we are led to conclude that conjoint therapy is a Yes, but… scenario – an option that many therapists utilize in practice even though there are mixed results in research. The aim of this paper is to lean into the Yes, and… approach of concurrent therapy, a modality which relies on its synergistic nature and might prove to be a viable solution to help therapists treat select clients more quickly and effectively.
References
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