Psychosocial Oncology and Palliative Care Department, Princess Margaret Hospital, Toronto, ON, Canada b Department of Psychology, Boston University, Boston, MA, USA c Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3 d Anxiety Treatment and Research Centre, St. Joseph’s Healthcare, Hamilton, ON, Canada e Department of Psychiatry and Behavioural Neurosciences, McMaster University f Mood Disorders Program, St. Joseph’s Healthcare, Hamilton Received 6 August 2005; received in revised form 11 June 2006; accepted 16 June 2006
Abstract Cognitive-behavior therapy (CBT) for Social Phobia is effective in both group and individual formats. However, the impact of group processes on treatment efﬁcacy remains relatively unexplored. In this study we examined group cohesion ratings made by individuals at the midpoint and endpoint of CBT groups for social phobia.
Symptom measures were also completed at the beginning and end of treatment. We found that cohesion ratings signiﬁcantly increased over the course of the group and were associated with improvement over time in social anxiety symptoms, as well as improvement on measures of general anxiety, depression, and functional impairment.
In conclusion, ﬁndings are consistent with the idea that changes in group cohesion are related to social anxiety symptom reduction and, therefore, speak to the importance of nonspeciﬁc therapeutic factors in treatment outcome. r 2006 Elsevier Ltd. All rights reserved. Keywords: Social phobia; Social anxiety disorder; Group cohesion; Cognitive-behavior therapy
Introduction Social phobia is characterized by an excessive fear of social or performance situations, during which a person may be scrutinized, judged, embarrassed, or humiliated by others. Evidence-based psychosocial treatments for social phobia have primarily come from a cognitive-behavioral orientation and include various combinations of four main components:
(1) exposure-based strategies,
(2) cognitive therapy,
(3) social skills training, and
(4) applied relaxation (for reviews, see Rodebaugh, Holaway, & Heimberg, 2004; Turk, Coles, & Heimberg, 2002).
Cognitive-behavioral treatment for social phobia has been shown to be effective when ÃCorresponding author. Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3, Canada. Tel.: +416 979 5000x2631; fax: +416 599 5660. E-mail address: [email protected] (M.M. Antony).
0005-7967/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2006.06.004
ARTICLE IN PRESS 688 M. Taube-Schiff et al. / Behaviour Research and Therapy 45 (2007) 687–698 administered in either individual and group formats (e.g., Heimberg, Salzman, Holt, & Blendell, 1993; Turner, Beidel, Cooley, Woody, & Messer, 1994). However, the mechanisms of change, and effective ingredients of these treatments remain relatively understudied.
Researchers have compared group and individual treatments for this condition, although evidence regarding the relative effectiveness of each approach has been inconsistent (see Scholing & Emmelkamp, 1993; Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003; Wlazlo, Schroeder-Hartwig, Hand, Kaiser, & Munchau, 1990 for direct comparisons of individual and group cognitive-behavioral treatment for social ¨ phobia).
However, for some patients, group treatment may offer a number of advantages over individual treatment. For example, group treatment provides an opportunity to marshal group processes (e.g., encouragement, support, and modeling from other group members) that may aid in teaching cognitive strategies and facilitating exposure exercises.
Further, there may be nonspeciﬁc effects that arise as a result of the relationships that form amongst group members that may contribute to therapeutic outcome. We decided to investigate how these group processes, particularly group cohesion, may be related to treatment outcome in cognitive-behavior therapy (CBT) groups for social phobia. Within the group therapy literature, one putative mechanism of change is that of group cohesion (Yalom, 1995). However, the construct of group cohesion has deﬁed ready operational deﬁnition, especially with more technique-driven interventions like CBT.
For example, a broad deﬁnition proposed to explain group cohesion is ‘‘the resultant of all forces acting on all the members to remain in the group’’ (Cartwright & Zander, 1962, p. 74) or, in simpler terms, how attractive a group is for the members who are in it (Frank, 1957). Yalom (1995) conceptualizes group cohesion as the ‘‘we-ness’’ that is felt amongst the group members. Groups with higher levels of cohesion are presumed to have a higher rate of attendance, participation, and mutual support, and to be likely to defend group standards much more.
Further, Yalom (1995) believes that group cohesion is necessary for other group therapeutic factors to operate. Researchers studying this construct have also included concepts such as a sense of bonding, a sense of working towards mutual goals, mutual acceptance, support, identiﬁcation, and afﬁliation with the group (e.g., Marziali, Munroe-Blum, & McCleary, 1997). Clearly then, cohesion is purported to be a critical ingredient for change and therefore would be expected to predict symptomatic outcomes. Some researchers investigating the relationship between group cohesion and treatment outcome have found positive results.
Although some of these studies have investigated other nonspeciﬁc therapeutic factors as well (i.e., the therapeutic alliance), the present discussion will focus on ﬁndings related to group cohesion processes. Studies have found that group cohesion is related to pre-treatment levels of symptomatic distress, improved self-esteem and reduced symptomatoloty (e.g., Budman et al., 1989).
A recent study by Tschuschke and Dies (1994) found that the level of group cohesion in the second half of a long-term psychoanalytic treatment for inpatients was signiﬁcantly correlated with treatment outcome and patients who made therapeutic gains reported a high level of group cohesion that began shortly after the ﬁrst few sessions. In contrast, unsuccessful patients did not experience a high level of group cohesion at any time.
Overall, these studies suggest that group cohesion may play a role in facilitating therapeutic change, though negative ﬁndings also exist (e.g., Gillaspy, Wright, Campbell, Stokes, & Adinoff, 2002; Lorentzen, Sexton, & Høglend, 2004; Marziali et al., 1997). In the CBT literature, researchers are increasingly paying attention to nonspeciﬁc therapeutic factors contributing to treatment outcome (e.g., Ilardi & Craighead, 1994; Kaufman, Rhode, Seeley, Clarke, & Stice, 2005). One of the ﬁrst studies in this area was conducted by Hand, Lamontagne, and Marks (1974) in treatment groups for individuals presenting with agoraphobia.
They found that members of the group in which cohesion was speciﬁcally fostered demonstrated greater improvement up to 6 months after treatment as compared to members of a less cohesive group who demonstrated a greater likelihood of relapse (see also Teasdale, Walsh, Lancashire, & Matthews, 1977, for a replication of these effects, albeit with weaker results).
Other ﬁndings from the CBT treatment literature include greater group cohesion ratings predicting lower physical and psychological abuse at follow-up in abusive men (Taft, Murphy, King, Musser, & DeDeyn, 2003), higher levels of group cohesion being signiﬁcantly related to decreased post-treatment systolic and diastolic blood pressure as well as improved post-treatment quality of life in cardiac patients (Andel, Erdman, Karsdorp, Appels, & Trijsburg, 2003).
In addition, group cohesion ratings have been found to be associated with improvements on depressive symptoms at treatment midpoint, after controlling for initial depression level (Bieling, Perras, & Siotis, 2003). Overall, these studies indicate that group cohesion may play some role in facilitating change or enhancing long-term beneﬁts in CBT-based treatments.
ARTICLE IN PRESS M. Taube-Schiff et al. / Behaviour Research and Therapy 45 (2007) 687–698 689
Although it is not yet clear what factors are relevant for fostering group cohesion, certain disorders may present more challenges than others. For example, given that social phobia involves an intense fear of scrutiny from other people, these individuals may present with barriers to forming a collaborative alliance, such as poor social skills, extreme sensitivity to evaluations, or social avoidance (Woody & Adessky, 2002). Only one study thus far has examined the development of group cohesion and its relationship to outcome during a group CBT treatment of social phobia.
Woody and Adessky (2002) treated individuals for social phobia in a group format using Heimberg’s (1991) protocol for group CBT for social phobia and had clients rate group cohesion using the Group Attitude Scale (GAS; Evans & Jarvis, 1986). The GAS measures the clients’ degree of attraction to the group. Measurements were conducted at three points during treatment (sessions 2, 5, and 9) and indicated that group cohesion remained static over time.
They also found that the level of group cohesion clients reported was in no way related to outcome. It was suggested that the constructs and measurement of group process in cognitive-behavioral approaches might need to be further reﬁned in order to more fully understand the degree to which group format and group process variables may add an important element to therapeutic outcome. It is important to note that the measure of group cohesion used by Woody and Adessky (2002) deﬁnes the construct unidimensionally.
The GAS was designed to measure only attraction to group, deﬁned as ‘‘an individual’s desire to identify with and be an accepted member of the group’’ (Evans & Jarvis, 1986, p. 204). Examples of items include: ‘‘I want to remain a member of this group,’’ ‘‘I feel involved in what is happening in my group,’’ and ‘‘In spite of individual differences, a feeling of unity exists in my group.’’ However, as discussed by Burlingame, Fuhriman, and Johnson (2002), elements of group cohesion may include both intrapersonal elements (e.g., group member’s sense of belonging and acceptance) as well as intragroup elements (e.g., attractiveness and compatibility felt among the group members).
Therefore, by solely focusing on attraction to the group it is possible that the GAS fails to operationalize aspects of cohesion that are important for making therapeutic gains. The present study, therefore, examined the role of cohesion in group CBT for social phobia, using a measure that includes items that ostensibly assess a number of different constructs thought to be related to group cohesion.
The Group Cohesion Scale-Revised (GCS-R), developed by Treadwell, Laverture, Kumar, and Veeraraghavan (2001), taps into several different aspects of group cohesion including: interaction and communication (including domination and subordination), member retention, decision-making, vulnerability among group members and consistency between group and individual goals. This self-report questionnaire has been shown to be both reliable and valid for detecting changes in group cohesiveness during the process of group development (Treadwell et al., 2001).
Clients with a principal diagnosis of Social Phobia were treated and, based on the preceding literature, we explored: (1) group cohesion development during the course of the group and (2) the relationship of group cohesion to treatment outcome, broadly deﬁned to include not only social phobia symptoms, but the overall experience of negative affect (e.g., general anxiety and depression) and functional impairment.
We hypothesized that group cohesion would increase from the midpoint of treatment to the endpoint of treatment and that group cohesion ratings would be signiﬁcantly related to positive treatment outcome (i.e., symptom reduction). Method Participants There were a total of 34 outpatient individuals in this study. The average age of participants was 36 years (range 19–64 years; 19 female, 15 male).
All individuals reported symptoms meeting criteria for a principal diagnosis (i.e., the diagnosis causing the most distress or impairment) of Social Phobia, as determined by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders—4th edition (SCID-IV; First, Spitzer, Gibbon, & Williams, 2001).
One individual also had symptoms meeting criteria for a co-principal primary diagnosis of Dyssomnia Not Otherwise Speciﬁed. For 32 of the participants, the social phobia was generalized (i.e., occurring in most social situations), whereas for the other two participants, it was nongeneralized, occurring in several, but not most social situations. Of the 34 participants, 57% reported symptoms meeting criteria for one or more additional mood disorder (Major Depressive Disorder, 47%; Bipolar Disorder, 6%; Dysthymic Disorder, 3%), 62% had one or more
ARTICLE IN PRESS 690 M. Taube-Schiff et al. / Behaviour Research and Therapy 45 (2007) 687–698