Ethics of Group Therapy, Research Paper Example

Abstract

The paper addresses the issues of the efficacy of group therapy and the advantages/disadvantages of group therapy against individual therapy according to an ethical emphasis on the priority of the individual who seeks therapy: therapeutic treatments should be approached on a case-by-case or contextual basis. This perspective is supported through a reading of the academic literature, in which empirical evidence is interpreted as stressing this approach to therapeutic treatment, insofar as conclusions regarding the most effective therapeutic treatment remain ambiguous.

Introduction

The analysis of the advantages and disadvantages of group therapy is complicated by the overall heterogeneity of the framework within which this concept is thought out. That is to say, many factors are constitutive of the group therapy experience; as such, group therapy is always context-dependent, such that the latter must be taken into consideration in order to provide a rigorous analysis of the concept. This context-dependency can be understood in various senses: a consideration of the individuals composing the groups clearly affects the efficacy of treatment according to personal histories: this is reflected in themes such as group composition and also the status of individual group members, insofar as some may be better suited for individual therapy according to personal idiosyncrasies. It is also crucial to underscore the precise disorder being treated in therapy: the attempt to meta-analyze group therapy in toto risks being ambiguous, as specific disorders and their receptivity to specific methodologies can be germane influences to the results produced by such analysis. Moreover, the theoretical approach used in therapy and the psychological-theoretical basis of the therapist can inform efficacy.

This basic typology of characteristics that constitute the potential efficacy of group therapy must obviously be addressed by psychologists who desire that an ethical foundation grounds their therapeutic practice. One of the main advantages of group therapy cited in the academic literature is its “cost-effectiveness”, insofar as “instead of providing services to a single client in a session, a group therapist can provide treatment to a number of clients at the same time.” (Hong & Domokos-Cheng Ham, 2001, p. 187) The reduction of a preferred approach to treatment is obviously ethically unsatisfactory, to the extent that economic factors define crucial health care decisions. Nevertheless, from a contrasting perspective, it could be argued that such cost-effectivity itself is ultimately ethical: forced by economic constraints, such as “limited public funding and resources” (Hong et Domokos-Cheng Ham, 2001, p. 188), the decision for group therapy may ultimately be the only efficient and practical means by which to provide therapy to a large number of patients.

According to the sheer number of constitutive factors regarding group therapy, the therapist is caught in a certain ethical bind as how to best approach individual cases – that is, whether individual therapy, group therapy, or combined individual-group therapy is the best approach. In both the acknowledgement of and response to such difficulty, Pope and Vasquez (2011) have suggested that a “standardized test” could aid in deciding if patients “will respond better to group than individual therapy.” (p. 191) In this regard, such an approach helps eliminate the number of elements that constitute the therapist’s decision about group therapy, essentially basing his or her decision on data that is given by the patient. This fundamentally ethical decision as to how to best treat patients may also be simplified through careful exegesis of the empirical scientific literature, which provides an invaluable foundation for providing aid in making therapeutic decisions for patients. The notion of such a standardized test, as Pope recommends, could be complimented by the therapist’s familiarity with the academic literature, in order to provide the best quality treatment. In short, empirical knowledge acquired through the academic literature helps make a more informed choice.

In light of the complexity of the problematic, the following paper, relying on empirical psychological studies, shall address the efficacy of group therapy, with a further emphasis on the debate between the efficacy of group therapy as opposed to individual therapy. The paper shall argue that although the academic literature is clearly invaluable to the decision making process of the therapist, there remains a particular ambiguity within the empirical data, particularly concerning whether group or individual theory is more efficacious. That is to say, the majority of the literature underscores the effectivity of therapy in both its group and individual forms; nevertheless, there remains ambivalence concerning which approach may be considered more effective. Instead of positing this ambivalence as an impasse to the decision making process of the therapist, the paper will argue that such ambivalence demonstrates the need to make such decisions as informed by context, such as particular disorders and individual cases. The error is to interpret this literature as providing some ultimate “meta-narrative” of truth for psychological practice; rather, this literature underlies the significance of dynamic practice, which adjusts to particular contexts. In light of the question of ethics, this approach seems to resemble the only radically ethical position a therapist can take, insofar an ethical commitment on the part of the therapist means an ethical commitment to the well-being of the patient.

The Ethics of the Analyst

In the context of our discussion, it is useful to begin with a brief recapitulation of some of the key ethical issues that inform the professional life of the therapist, and moreover, to understand how ethics relates to psychological theory and practice.

The extent to which the psychological profession remains an ethical profession suggests that the treatment methods and therapeutic approaches pursued by the analyst possess the teleological goal of the patient’s well being. Insofar as the latter remains paramount, this suggests that the therapist must essentially remain heterogeneous in both his or her theory and practice: the analyst must continually remain open to new approaches, in order to provide the most efficacious therapy, such that, for example, a continual immersion in the academic literature is not only a practical and theoretical exercise, but moreover, is indicative of an ethical commitment.

When considering the efficacy of group therapy and the debate over individual and group therapy, such analyses themselves can be considered as reflective of such an ethical commitment to the best possible care to the patient. That is, that such issues remain prescient is a vindication of psychology’s ethical center. It is important to underscore this background to the problematic of group therapy, as one can then understand that the existence of this problematic itself is coextensive with an ethical decision. Accordingly, such an approach may, in one sense, help reconcile the heterogeneity of the overall problematic, as an ethical perspective drives the approach to the academic literature: namely, what one seeks out in the literature are the treatment methods that will yield the best results for the patient. As Geoff Lindsay (2009) suggests, psychology is founded on two foundations: “the first foundation comprises a body of knowledge and skills which have been built up from research and from the practice of psychology. The second comprises the ethics of developing that knowledge and skills base, and of the actions taken when applying to meet demands for services to be delivered to the public.” (p. 184) Hence, these two foundations are not distinct, but rather, it is the ethical foundation that gives a meaning to the epistemological foundation.  In other words, empirical literature becomes a means with which to support a basic ethical commitment, whereas an ethical foundation provides one with a roadmap as to how to best approach the literature.

Another crucial point when considering the ethical-empirical relationship is the diversity of the field of psychology itself. As Lindsay (2009) writes, “psychology as the study of behaviour and the mind covers a vast range. Consequently, the context of each particular research study will raise different ethical questions.” (p. 184) Accordingly, context related issues complicate the empirical and ethical nexus of psychology: to maintain an ethical approach, one must consider the context, as opposed to forcing an ethics upon a situation; concomitantly, the empirical literature is to be read in a manner that stresses the different contexts, such as particular disorders, in which analysis is carried out and presented.

When considering the topic of group therapy in light of these points, it becomes clear that a decisive verdict on the efficacy of group therapy as gained through the empirical literature misses the point that each case should be considered as contextually independent. The ethical commitment to the treatment of the patient is determined by the patient, not by the presupposed ethical foundation. Group therapy needs to be approached from the perspective of those within the group or those who may potentially be a part of the group. Furthermore, the empirical literature, although valuable, must always be viewed in its proper context: empirical literature is a means with which to aid the therapist to think through particular therapeutic situations, as opposed to providing a definitive decision as to treatment approaches. As the paper shall argue, the empirical literature on group therapy itself supports this stance, insofar as a certain ambiguity within the academic literature highlights the necessity of a context-based approach.

Literature Review

Our literature review of group therapy, with an intent to support the thesis that a context-based approach to therapy is the most efficacious and ethical approach, will concentrate on two types of literature relevant to the thematic: empirical studies that treat the efficacy of group therapy directly, and empirical studies that address the comparison of the efficacy of group and individual therapy. Accordingly, it is practical to begin with reviews of literature addressing the latter comparison, insofar as analyses that suggest the overwhelming efficacy of individual therapy over group therapy would imply that, from an ethical perspective, the maintenance of group therapy approaches is untenable, except in situations in which cost-effectiveness is a crucial factor. As the literature review shall endeavor to demonstrate, however, the efficacy of one approach over the other remains an open question.

McRoberts, Burlingame, and Hoag (1998) provide a valuable empirical analysis intended to discern the effectiveness of psychoanalytic group therapy against psychoanalytic individual therapy.  They begin with a summary of some of the previous findings on group therapy, stressing that it has been demonstrated to be practically effective and also cost effective. (McRoberts et al., 1998, p. 101) Furthermore, the relevance of the comparison of individual therapy to group therapy is relevant because “collective findings on the differential efficacy of group when compared with individual therapy remain problematic, incomplete or controversial.” (McRoberts et al. 1998, p. 101) The authors suggest that empirical studies have also maintained the effectiveness of individual therapy, such that the conclusion can be made that therapy, whether in a group or individual form, is “significantly more effective than no treatment or minimal treatments for a variety of disorders and over a variety of different client groups.” (McRoberts et al., 1998, p. 101)

Two points are crucial in this analysis. Firstly, individual and group therapies empirically demonstrate their efficacy irrespective of psychological theoretical approaches, differences in disorders; and the particular individuals undergoing treatment.  Accordingly, it can be said that this efficacy reveals itself outside of context – therapy is across the board effective, according to the authors’ meta-analysis of the empirical literature. However, this general efficacy appears in light of lack of treatment and/or minimal treatment, such that both group and individual treatments are preferable to the latter: the question remains open as to the most effective therapeutic approach. Accordingly, the authors maintain the importance of context, insofar as the efficacy of particular therapeutic approaches remains prescient despite general therapeutic efficacy.

The authors employ a methodology of meta-analysis that “combines statistical results from a number of primary outcome studies into a common metric…which allows conclusions to be drawn on the basis of the results of many researches.” (McRoberts et al., 1998, p. 101) Thus, the authors accept such a meta-analytic approach as sufficient to address the contextual heterogeneity of various therapeutic scenarios. This meta-analysis, however, does not discount contextuality, as “an important component in delineating the comparative efficacy of group and individual therapies is determining whether and under what circumstances one therapy format might be more beneficial to clients than the other format.” (McRoberts et al., 1998, p. 101) Accordingly, circumstances or context clearly underline the merits of any decision and possible empirical data present within this analysis. At the same time, the authors underline that what exactly constitutes group therapy is in itself heterogeneous, citing two previous similar meta-analyses, which  “did not investigate group therapy as it is thought of in the traditional sense, but rather, investigated group as a cost effective vehicle for the delivery of a treatment package originally designed for use in individual therapy. In other words some of the studies included in these meta-analyses could best be described as individual treatment in the presence of others.” (McRoberts et al., 1998, p. 101) The concept of group therapy itself needs to be clearly delineated in such empirical analysis, in order to avoid the conflation that is evident in the situation in which individual therapy is performed in a group therapy setting. Using articles in which individual and group psychotherapy are compared in a singular study, the meta-analysis reveals the shared effectivity of both approaches, as “individual therapy patients fared better on average than 78% of wait-list patients, and group therapy patients fared better on average than 82 of wait-list patients.” (McRoberts et al., 1998, p. 107) The similar result of this success rate suggests that there is no pertinent difference in such approaches. However, this lack of difference does not correspond to the irrelevance of the question, as there is a lag in research concerning  “differential effectiveness between group and individual treatment with adults…with comparable research investigating individual and group therapy separately.” (McRoberts et al., 1998, p. 114) Whereas separate contexts are being researched, there is a lack of literature addressing a comparison, or intra-contextual approach, which gives a context its very meaning: Accordingly, the absence of comparative literature can be regarded, extrapolating on the author’s conclusions, as a failure to effectively consider alternative treatment approaches by the therapists, who remain committed to their own preferred approach: ultimately, there is no comparison of different approaches, which is the rejection of contextual pertinence.  Accordingly, the similar efficacy of individual and group therapies would seem to be the result of the overall efficacy of therapy in general, as opposed to the efficacy of one approach compared to another.

Nevertheless, other academic literature also seems to support this same similarity in efficacy in regards to various psychological disorders. A study conducted by Liber et al., (2008) which examines group and individual treatment in the specific context of childhood anxiety disorders, concludes that “the delivery of manualised cognitive-behaviour therapy (FRIENDS) for children with anxiety disorders…showed no significant difference in outcome between individual and group treatment.” (p. 886) Thus, the greater meta-analysis of McRoberts et al. and the specific anxiety disorder research of Liber demonstrate a similar effectivity: The shared success of these treatments suggests that the choice for individual or group therapy is immediately a non-issue, and therefore a choice without therapeutic consequences for the therapist. Furthermore, Churchill et al.’s (2001) study on brief psychological treatments for depression stresses this same overall efficacy of therapy: “patients receiving any variant of psychotherapy were significantly more likely to improve to a degree where they were no longer considered clinically depressed” (p. 2), while also concluding that “little can be said about the efficacy of different types of individual versus group therapy” (p. 3). Another relevant example is the psychological treatment of obsessive-compulsive disorder, analyzed in a meta-analysis by Rosa-Alcazar et al. (2008), in which general therapeutic effectivity was also discerned, however without any simultaneous conclusions yielded by the data as to whether group or individual therapy is more effective.

This lack of difference between group and individual therapy thus opens, in the words of Ahn and Wampold (2001), the “controversy about whether the beneficial effects of counseling and psychotherapy are due to the specific ingredients of the treatments or to the factors common in all therapies.” (p. 251) In other words, the apparent lack of significant difference between individual and group therapy, as demonstrated in the four aforecited empirical studies, suggests that therapy needs to be analyzed in terms of specific contexts, i.e., of specific treatments, in order to fully understand the difference between therapy in itself and therapy in its various forms. In the empirical study conducted by Ahn and Wampold (2001) that employed a meta-analysis of relevant literature, the authors conclude that “the results cast doubt on the specificity of psychological treatments.” (p. 251) The literature thus presents a strong case for the insignificance of distinctions between types of therapy, such that therapy itself is clearly effective, whereas the particular therapeutic process, such as group or individual therapy, is essentailly irrelevant.

Yet such a conclusion becomes challenged when literature on group therapy itself is considered. For various studies have declared a relevance to the concept of group composition when positing the successes of group therapy. Thus, Piper et al. (2007) in their paper on “Group Composition and Group Therapy for Complicated Grief”, examined the “impact of group composition on 2 forms of time-limited, short-term group therapy”, (p. 116) in which group composition is defined by the authors as the “combination of individual characteristics.” (p. 116) The results concluded that “the higher the percentage of patients in a therapy group who had a history of relatively mature relationships, the better the outcome for all patients in the group, regardless of the form of therapy.” (Piper et al., 2007, p. 116) In the study a crucial distinction was made between homogeneous groups, in which participants possessed a shared combination of individual characteristics, and heterogeneous groups, defined as groups that lack such shared characteristics. (Piper et al, 2007, p. 116) The empirical study of homogeneous and heterogeneous groups, based on a sampling of 118 outpatients from 18 therapy groups, concluded that a homogeneous group is more effective than a heterogeneous group. (Piper et al., 2007, p. 116) The effectivity of group composition determined through empirical research demonstrates a “composition effect”, which the theoretical literature had suggested, although which had remained absent in practice (Piper et al., 2007, p. 123): this composition effect functions as empirical evidence for the relevance group composition. Yet Piper et al., (2007) nevertheless stress that such a composition effect is the direct result of their concentration on a particular context, according to the specific delineation of the variables of this context, which in the case of this study is summarized as follows: “the specific nature of the composition variable, the nature of the patients’ common problem, and the type of treatment.” (p. 123) Accordingly, a greater composition effect relevant to all forms of group therapy remains debatable; nevertheless, by specifying a certain case, this composition variable, in the context of grief therapy, became apparent. (Piper et al, 2007, 123) Yet whether a greater composition effect can be found is, in one sense, beside the point; as the appearance of a composition effect underscores the relevance of context when considering the merits of group therapy, and furthermore, of individual as opposed to group treatment: theoretical approaches should not be defined by the extrapolation of empirical data addressing particular cases, but should rather stress the primacy of the practical context, such as grief therapy.

Yet other studies have also determined a significance to such group composition. The Importance of group composition is explicitly stated by Burlingame, Fuhriman and Mosier (2003), in their meta-analysis of group psychotherapy effectiveness, as “the meta-analysis of 111 experimental and quasi-experimental studies published over the past 20 years” (p. 111) suggests that improvement in  treatment “was related to group composition.” (p. 111) This is especially relevant, insofar as group composition “is one of the least studied factors in all the group empirical history.” (Burlingame, Fuhriman & Mosier, 2003, p. 111) As in Piper et al.’s (2007) research, the findings suggest that homogeneous groups with a clear topic – and moreover short-terms groups  – are more efficacious. (Burlingame, Fuhriman & Mosier, 2003, p. 111) A similar conclusion is also presented in Rohde’s (2008) statistical analysis of two randomized trials of group intervention, which further underscores the importance of group composition: “Individuals that attended groups that are cohesive, retain members, and are consistently attended are more likely to have good outcomes, whereas individuals attending groups that are unfriendly, lose members, and are poorly attended are more likely to have poor outcomes.” (p. 365)    The importance of factors such as group composition and group homogeneity suggests that the notion of group therapy itself is not homogeneous: there are different types of group therapy, as evidenced by group composition that is homogeneous and heterogeneous; moreover, these different types of group therapy are relevant, to the extent that the empirical literature shows that homogeneous groups are more effective in therapy goals. Accordingly, when considering the advantages and disadvantages of group therapy, it is crucial to understand what type of group therapy one is talking about. The efficacy of homogeneous groups in group therapy and the importance of group composition to group therapy suggests that the decision in favour of group therapy must be preceded by questions concerning group composition and the possibility of creating a homogeneous group.

In relation to the consideration of the merits of group therapy as opposed to individual therapy, what is striking in the literature is the certain aporia it presents: the aforecited comparative empirical analysis suggests that there is no significant difference between group and individual therapy; at the same time, the literature concludes there are differences in efficacy between types of group therapy. The paradox here is clear, as the problem becomes how to reconcile the academic literature that suggests no difference in efficacy between individual and group therapies with the literature that suggests that group composition is crucial, which denotes different success rates for various forms of group therapies.

This contradiction in the literature suggests that meta-analyses that do not consider context are insufficient. Studies, such as Piper’s (2007), become more relevant, insofar as they treat a specific contextual problem, i.e., grief therapy, and then make conclusions about the relevance of group composition based on this context. The meta-analysis ignores these context, lumping together forms of group therapy and of individual therapy: this implies that the crucial decision for the psychologist is not the efficacy of group therapy contra individual therapy, but rather lies in the consideration of the specific therapeutic situation and to thereafter act accordingly. The ambiguity in the data should not be viewed as a failure in analysis, but rather supports the thesis that the therapeutic approaches, types of diagnoses and the clinical problems faced by the psychologist are simply too diverse to provide an over-arching meta-narrative:

An example of an empirical study that takes into account such notions is that of Rubeis and Crits-Christoph (1998), who summarize their overall theoretical approach as follows: “we are aware of the limitation of any such attempt to declare “the truth” about the effectiveness of psychological treatments.” (p. 37) Obviously, this is not a commentary on the effectiveness of treatment as a whole, but rather a movement away from attempts to provide a grand truth about therapeutic theory and practice, in favor of approaches that stress context. Accordingly, Rubeis and Crits-Christoph (1998) provide empirical data on efficacious treatments in terms of specific diagnoses and clinical problems, such as anxiety disorder and dependency issues. For example, behavioral treatments are especially efficacious in the case of anxiety disorders, however, as the authors stress, not without exception. (Rubeis and Crits-Christoph, p. 37, 1998) Such a context-based approach is also found in the research of Sin and Lyubomirsky (2009), which addresses the efficacy of the specific theoretical therapeutic approach of positive psychology. The meta-analysis carried out suggests that positive psychology interventions are in fact beneficial, (Sin and Lyubomirksy, 2009, p. 467), but more important to the framework of our discussion, such interventions are more appropriate for individual therapy as opposed to group therapy. This type of meta-analysis thus isolates a specific form of treatment and then gauges its effectivity according to individual and group settings; a more detailed context-based analysis could be performed, for example, in which such intervention is posited in terms of homogeneous of heterogeneous groups.

Accordingly, the apparent contradiction that arises between research that maintains no difference in efficacy between individual and group therapy, and research that maintains efficacy differences in group composition, and thus, differences in efficacy within group therapy itself, demonstrates the futility of approaching therapy from a top-to-bottom approach. It is difficult to register the nuances of particular treatment forms, without stressing contexts, such as in the work of Piper et al. (2007), Rubeis and Crits-Cristoph (1998), and Sin and Lyubomirsky (2009). Moreover, Sin and Lyubomirsky (2009) demonstrate how empirical research in the form of meta-analyses can also remain sensitive to contextual concerns.

Such research demonstrates that the merits of group therapy itself must be broken down into questions of group composition and the consideration of various disorders. From an ethical perspective that maintains a commitment to the patient, this approach seems most effective, as opposed to the postulation of monolithic entities such as group therapy against individual therapy. The empirical research is arguably more accurate and effectively employed when approached in this manner.

Personal Reflection on Ethical Considerations

The diversity of the academic literature on group therapy and group therapy pace individual therapy provides a germane foundation for an encounter with personal views on the therapeutic relationship. According to the interpretation presented above, such diversity supports the importance of a context-related approach: this is not only necessary in order to reconcile the apparent paradoxes that have been identified in the literature, but is moreover expressive of ethical considerations in the therapeutic relationship. From my own subjective perspective, it is thus an ethical approach to psychology that determines both my prospective practice and interpretation of psychological theory. According to this viewpoint, ethics can be considered as a required precondition to therapeutic practice.

The fundamental ethical foundation which I have attempted to advance in this paper is the primacy of the patient: this could be simply formulated as taking individuals on a case-by-case basis. In this regard, the question of the efficacy of group therapy and the related question of the efficacy of group therapy as opposed to individual therapy is determined by the particular subject of therapy. Accordingly, prospective therapeutic approaches and treatments must be evaluated on such a case-by-case basis. The decision that a particular individual would most benefit from, for example, group therapy or individual therapy is considered according to the perspective of this same individual. The empirical articles that demonstrate a certain equality between group and individual approaches underscores the need to identify what is best for a particular patient.

Furthermore, in the case of group therapy, a crucial insight gained from the study of the empirical literature is the importance of group composition. If I were to engage in the therapeutic practice, the possible assignment of an individual to a group therapy session would thus be dependent upon the possibility of forming a homogeneous group, with the caveat that this, of course, is derivative of the particular disorder experienced by the patient, and moreover, the patient’s own wishes. Accordingly my approach to group counseling can be summarized as: 1) an attentiveness to the concerns of the individual 2) an attempt to form an appropriate group according to similar concerns of individuals, in order to ensure group homogeneity. In the case that the second option is unattainable, serious consideration would be given to individual therapy.

The above approach is, once again, an essentially ethical approach that focuses on the individual needs of those undergoing therapy. This ethical approach informs questions of my own leadership qualities; in other words, whatever I may posit as my own presupposed leadership qualities, the latter must be directed towards individual needs. According to such an ethical consideration, it could be said that one defers at the outset the notion that the therapist is the leader, rather assuming a passive role, in order to fully grasp the concerns of the individual. This initial passivity is followed by an active appropriation of the leadership role, as tasks such as formation of a homogeneous group for group counseling sessions remain the initiative of the therapist. Moreover, the therapist must guide this group therapy in an effective manner, for example, using leadership qualities to further develop the homogeneous relationships based on the shared backgrounds between group members. While I believe I have the personal leadership qualities to realize this process, I concomitantly understand that such qualities may be further developed through both therapeutic practice and a theoretical attentiveness to the literature, in which leadership is demonstrated through the active engagement with relevant theoretical texts according to the emphasis on context that I have developed in this paper.

A biblical relevance and a Christian ethics fundamentally informs this approach. Whereas biblical exegesis remains obviously subject to the vicissitudes of hermeneutics, the ethical kernel of Christianity can be viewed as precisely the deferral of the needs of the individual to the needs of the other. This biblical integration of ethics into the therapeutic process implies a distancing from any meta-narratives of theoretical psychological practice, precisely in favor of a beginning point that starts from the other understood as the individual seeking counsel and therapy.

Works Cited

Ahn, H. and Wampold, B.E. (2001). Where Oh Where are the Specific Ingredients? A Meta-Analysis of Component Studies in Counseling and Psychotherapy. Journal of Counseling Psychology, Vol. 48, No. 3, 251-257.

Burlingame, G.M., Fuhriman, A., and Mosier, J. (2003). The Differential Effectiveness of Group Psychotherapy: A Meta-Analytic Perspective. Group Dynamics: Theory, Research, and Practice, Vol. 7, No. 1, 3-12.

Churchill, R., Hunot, V., Corney R., Knapp, M., McGuire, H., Tylee, A., Wessely, S. (2001). A Systematic Review of Controlled Trials of the Effectiveness and Cost-Effectiveness of Brief Psychological Treatments. Health Technology Assessment, Vol. 5, No. 35, 1-6.

Kong, G.K. and Domokos-Cheng Ham, M.A. (2001). Psychotherapy and Counseling with Asian American Clients: A Practical Guide. New York: SAGE.

Liber, J.M., Widenfelt Van, B.M., Utens, E.M.W.J., Ferdinand, R.F., Van der Leeden,

A.J.M., Van Gastel, W., Treffers, P.D.A. (2008). No Differences Between Group Versus Individual Treatment of Childhood Anxiety Disorders in a Randomised Clinical Trial. The Journal of Child Psychology and Psychiatry. Vol. 49, No. 8., 886-893.

Lindsay, G. (2009). Professional Ethics and Psychology. Papeles del Psicologo. Vol. 30, No. 3, 184-194.

McRoberts, C., Burlingame, G.M., and Hoag, M.J. (1998). Comparative Efficacy of Individual and Group Psychotherapy: A Meta-Analytic Perspective. Group  Dynamics: Theory, Research and Practice. Vol. 2, No. 2, 101-117.

Pope, K.S. and Vasquez, M.J.T. (2011). Ethics in Psychotherapy and Counseling: A Practical  Hoboken, NJ: John Wiley & Sons.

Piper, W.E., Ogrodniczuk, J.S., Joyce, A.S., Rosie, J.S., Weideman, R. (2007). “Group Composition and Group Therapy for Complicated Grief.” Journal of Consulting and Clinical Psychology, Vol. 75, No. 1, 116-125.

Rohde, P.D. (2008) Statistical Analysis of Group-Administered Intervention Data: Re-Analysis of Two Randomized Trials. Psychotherapy Research, Vol. 18, No. 4, 365-376.

Rosa-Alcazar, A.I., Sanchez-Meca, J., Gomez-Conesa, A., and Marin-Martinez, F. (2008). Psychological Treatment of Obsessive-Compulsive Disorder: A Meta-Analysis. Clinical Psychology Review, Vol. 28, Issue 8, 1310-1325.

Rubeis, R.J. and Crits-Christoph, P. (1998). Empirically Supported Individual and Group Psychological Treatments for Adult Mental Disorders. Journal of Consulting and Clinical Psychology, Vol. 66, No. 1, 37-52.

Sin, Nancy L. and Lyubomirsky, S. (2009). Enhancing Well-Being and Alleviating Depressive Symptoms with Positive Psychology Interventions: A Practice-Friendly Meta-Analysis. Journal of Clinical Psychology: In Session, Vol. 65, No, 5, 467-487.