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.