Abstract
There are many psychotherapy varieties, but all are delivered through two predominant modalities—individual and group. This article outlines differences between individual and group treatment and the advantages and disadvantages of each. The author focuses on psychodynamic treatment, but the differences between the two modalities apply across all theoretical orientations. Human beings are social animals with an innate drive for relationships. With the advent of mass transit and mass communication, many historic bastions of relationships, such as the family, the neighborhood, and religious institutions, have been disrupted, and the roots of relationships have become shallow. As a result, many people seek psychotherapy to help build and sustain more intimate and healthier relationships, a goal for which group therapy is well suited. As relationships develop in group psychotherapy, group members demonstrate the assets and liabilities of their relational styles. Their defenses against intimacy become apparent. For these reasons, group therapy is the treatment of choice for many people. The interpersonal nature of group psychotherapy provides an opportunity to recognize interpersonal behavior patterns and thus may provide tools to allow for more intimate relationships. When meeting a new patient, the therapist seeks not only the theoretical treatment that might be most amenable to the patient’s individual needs but also the form of therapy that might work best. The aim of this article is to examine the unique features of group therapy and of the patients this modality may especially help.
Research has demonstrated that both individual (1, 2) and group therapy (3) can help patients live more fulfilling and happier lives, although studies have also suggested that whichever modality the therapist prefers shows more efficacy. In examining 67 studies that compared formats, Burlingame et al. (4) found no difference between formats for “rates of treatment acceptance, dropout, remission, and improvement.”
Group therapy may have special utility in current society, as societies worldwide seem to be splitting into us-versus-them camps. One great asset of therapy groups, in which people are offered the opportunity to be honest with one another in a safe setting, is that participants typically come to find that people are ultimately more alike than different, regardless of color, religion, or political stance.
As psychodynamic theory has become less inward and more relational in focus, this premise that people are more alike than different increasingly applies. Intersubjectivity, humanistic theory, relational therapies, and object relations theory all emphasize various aspects of human relatedness as key to diagnosis and healing. “Object relations theory begins by assuming that people are born seeking and needing relationships. . . . The degree to which those behaviors fail to accomplish that goal has to do with members’ needs to feel safe and protect themselves” (5). It could be argued that the most prevalent psychiatric problems today are object-relational disorders. This is particularly problematic because “human beings are herd animals. We begin in small groups—our families—and live, work, and play in various groups” (6). I wrote this article during a pandemic, at a time when our natural groups have been severely disrupted.
History of Group Therapy
Many cite Joseph H. Pratt (7) as the first group therapist, because he assembled his 15 tuberculosis patients into groups at the Massachusetts General Hospital, where they talked about their illnesses and problems and agreed on a set of guidelines defining how the groups would operate. Pratt reported that patients who participated in these groups responded better to their tuberculosis treatment than those who did not. But those groups, which engaged in activities such as lectures and outdoor meetings, bear little resemblance to modern psychotherapy groups.
For all practical purposes, modern group psychotherapy traces its origins to the military during World War II, when the number of patients far exceeded the number of providers. Field doctors, medics, and nurses were instructed to see patients in groups. Although these caretakers had no formal training in group therapy or group process, it quickly became evident to them that something powerful happened when soldiers were seen in groups. The whole effect of group treatment was much larger than the sum of individual outcomes. Since that time, practitioners have been trying to harness the power of groups to help patients most effectively.
Despite immediate public acceptance of group therapy in the 1950s and 1960s, as evidenced by the plethora of “sensitivity groups” that developed during the decades after the war (cf. the Esalen Institute and the 1969 movie Bob and Carol and Ted and Alice), the influential psychoanalytic community pushed back against the idea. Analysts, who relied on therapist opacity to foster transference, were wary of the group setting, where therapist opaqueness would be much less possible. Perhaps because of this early conflict, group therapy has struggled through the years to be viewed as equal to individual therapy in effectiveness (8). “Given the fantasied blissful relationship of the maternal dyad that persists in our culture as the ideal symbiosis, it is always a challenge to present the patient with group therapy as a full-fledged treatment model on a true par with individual treatment” (9).
Similarities and Differences in How Group and Individual Therapy Work
The most consistent finding in the outcomes literature (10) is that the quality of the relationship between the therapist and the patient has more impact on outcome than any other variable. This is true in both group and individual therapy, although Holmes and Kivlighan (11) argue that individual therapy is more self focused, and group therapy is more relationship focused. In this context, group therapy makes greater use of the power of relationships, not only with the therapist but also with peers.
A patient in an individual therapy session has a markedly different experience than a patient in a therapy group. In the former, there is a clear power differential, whereas in the latter, there are peers. In the former, trust must be formed with one professional, whereas in the latter, trust must be formed with multiple others who are not sworn to professional roles and indeed have agreed to share their feelings freely. Although quite different, the two settings are both powerful.
Patient’s defenses appear and are considered differently in the two settings. For example, one common and powerful defense readily available for exploration in group therapy is projective identification (which Shay [12] has suggested renaming as “projective recruitment”).