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Psychotherapy

2011, Vol. 48, No. 1, 34 – 42

© 2011 American Psychological Association
0033­3204/11/$12.00  DOI: 10.1037/a0022063

Cohesion in Group Therapy
Gary M. Burlingame, Debra Theobald McClendon, and Jennifer Alonso
Brigham Young University

Cohesion  is  the  most  popular  of  several  relationship  constructs  in  the  clinical and empirical  group
therapy literature. This article reviews the most frequently cited definitions and studied measures of
group cohesion. We briefly introduce a new measure, the Group Questionnaire, which elucidates group
relationships by suggesting two latent factors of cohesion—relationship quality (positive bond, positive
work, and negative relationship) and structure factors (member­leader and member­member). To further
understand the literature, we conducted a meta­analysis examining the relationship between cohesion
and treatment outcome in 40 studies. Results indicate cohesion that the weighted aggregate correlation
was statistically significant with outcome r .25, k (40), N (3,323), z 6.54 ( p .05) with a 95% confidence
interval  of  .17  to  .32. In addition,  five   moderator  variables  were  found  to significantly  predict  the
magnitude of the cohesion outcome correlation (age, theoretical orientation, length, and size of group, as
well as interventions intended to enhance cohesion). Consideration of measures and practices to improve
treatment outcome are highlighted.
Keywords: group therapy, cohesion, therapy relationship, meta­analysis

Cohesion is the most popular of several relationship constructs (e.g.,
alliance, group climate, group atmosphere) in the clinical and empirical
literature   on  groups.   Over   time  it  has   become  synony­mous   with  the
therapeutic relationship in group psychotherapy (Burlingame, Fuhriman,
&   Johnson,   2002).   From   the   perspective   of   a   group   member,
relationships   are   comprised   of   three   structural   components:   member­
member, member­group, and member­leader.  From  the perspective of
the therapist, relationships include the same three components as well as
two additional: leader­group and, in the case of a cotherapist, leader­
leader. The complexity of these multilevel structural definitions coupled
with   the   dynamic   interplay   among   them   has   created   an   array   of
competing   cohesion   instruments   and   an   absence   of   a   consensual
definition.
In  this  article,  we  review  the  multiple  definitions  and  measures  of
group cohesion and then discuss a new measure that contains two latent
factors   that   explain   common   variance   among   these   group   therapy
relationship instruments— quality and structure. We provide a clinical
example to illustrate the multiple facets of cohesion in group work. We
then present an original meta­analytic review of cohesion’s relation with
outcome   and   discuss   potential   moderators,   ending   with   a   tabular
summary  of  therapeutic  prac­tices  that  have   been  linked  to  increased
cohesion.   Our   intent   is   to   illuminate   the   coherence   in   the   cohesion
literature, present the

Gary M. Burlingame, Debra Theobald McClendon, and Jennifer Alonso,
Department of Psychology, Brigham Young University.
This article is adapted, by special permission of Oxford University Press,
from a chapter of the same title by the same authors in J. C. Norcross (Ed.),
2011,  Psychotherapy   relationships   that   work  (2nd   edition).   New   York:
Oxford University Press. The  book project  was cosponsored by the  APA
Division of Psychotherapy.
Correspondence concerning this article should be addressed to Gary M.
Burlingame, Brigham Young University, 238 TLRB, Provo, UT 84602. E­
mail: gary_burlingame@byu.edu

meta­analytic   conclusions,   and
offer measures and practices to
improve treatment outcomes.

Definitions 
and 
Measures
Definitions   of   cohesion   have
traveled   a   serpentine   trail
(Bednar   &   Kaul,   1994;
Kivlighan,   Coleman,   &
Anderson,   2000)   ranging   from
broad   and   diffuse   (e.g.,   forces
that cause members to remain in
the   group,   sticking­togetherness)
to   focused   (e.g.,   attractiveness,
alliance)   and   structurally
coherent   (e.g.,   tripartite
relationship;   Yalom   &   Leszcz,
2005).   At   different   times,
reviewers   have   pled   for
definitional   clarity,   with   two
noting   that   “there   is   little
cohesion   in   the   cohesion
research” (Bednar & Kaul, 1978,
p.   800).   Indeed,   instruments
tapping   group   acceptance,
emotional   well­being,   self­
disclosure,   interpersonal   liking,
and tolerance for personal space
have   been   used   as   measures   of
cohesion   (Burlingame   et   al.,
2002).   Behavioral   definitions
have included attendance, verbal
content,   early   termination,

 Dwyer. 2007).physical seating distance. & Dingle.   Of   note   is   our   argument that the use of different measures .   while tionship quality. McClendon. p. amount of eye contact.   All   assess After reviewing the literature.   2011). Oei.   In   a   similar manner. 1 in Burlingame. and the length of time frequently   studied   in   the group members engaged in a group hug (Hornsey. & Oei. & Alonso. we believe the evidence supports two horizontal   cohesion   between fundamental   dimensions   of   cohesion:   relationship  structure  and   rela­members   and   their   group. literature   and   classified   each The   definitional   challenges   of   cohesion   are   reflected   by   one   team’s measure   by   its   use   of   the observation that “just about anything that has a positive valence [with structural   and   affective/task outcome] has been interpreted at some point as an index of cohesion” definitions of cohesion (see Table (Hornsey. 272). 2009. Dwyer.   affective   bond   is universally   assessed   by   all measures while the task cohesion is assessed by a third of the mea­ sures. We identified nine measures of cohesion that were most 34 fewer   than   half   focus   on   a member’s   relationship   with   the leader   (vertical).

 these authors found support for indicates   that   members   are   drawn   to   the   group   tothree structural components (member­ accomplish   a   given   task   or   goal. The   first   dimension   of   coherence. 2000).   &   Strauss.   &   Gleave.   Using   a   sample   of   485   group factor structural dimension: member­leader and member­ members. Both em­ Burlingame. the   first   study   (Johnson   et   al. ultimately   identify   accurate   group   therapy   measures.  and  negativequality   and   structural   factors relationship factors explained how members perceived the (Burlingame.   2009). The   second   dimension   of   cohesion   is   relationship and   reported   a   similar   two­ quality.   member­leader. that contained over 80 items. The first study (Johnson. & Ruud. 2002).35 SPECIAL ISSUE: COHESION IN GROUP THERAPY member­member)   stimulated would likely produce varied results.   2005).   genuineness   and   warmth. 2007) collected relationship.   while   vertical cohesion   captures   the   qual­ity   of member­to­leader   relationships.   We   found the   model   would   be  applicable   to  that interesting that when examining the structure of the group.   we&   Lorentzen.   2010).  structure.   while   affectivemember. Table   1b   depicts   how   horizontal   and vertical   cohesion   load   on   the relationship   structure   dimension.   Following additional   studies.  Modified  framework  for  understandin g cohesion  using  relationship quality Relatio . The   three  relationship  quality  factors   (  positive   bond. 2008) tested   the   same   toolkit   of   measures (Dion. Findings from these studies led to an Burlingame.   Davies. As   can   be   seen.   2009.  positive   bond.  negative   relationship)   and   two   structural These   studies   support   structure   and quality   as   the   two   funda­mental factors (member­leader and dimensions   of   cohesion. Questionnaire   that   measured   the   three Specifically. 2008). 2010).   It   is interesting that the individual   working   alliance.   positive   work.   and cohesion indicates members feel connected because of member­group). be identified from the original measures Burlingame. from   member­to­member   relationships   yielding   a   two­ 2009). even if measuringsubsequent   studies   that   attempted   to replicate these findings across clinical the same group (Burlingame et al.   we   arrived   at   a  40­ item   instrument   called   the   Group Table 1 Questionnaire   that   measures   the   three a . & Bormann..   affective   cohesion   is split   by   the   emotional   valence   of   the item loading either on the positive bond or   negative   relationship   dimensions. task cohesionstudy.   Mackenzie. vertical cohesiondata from 67 inpatient psychodynamic refers   to   a   group   member’s   perception   of   the   groupgroups   drawn   from   15   hospitals   in leader’s   competence.   and   group   climate.other members and the group. Table 1a weds the past   definition   of   affective   and   task cohesion   dimensions   with   the relationship structure and quality model.   they   found   the   same   two­ dimensional   relationship   quality   and member.   In   order   to   condense   the   literature   and stage   of   treatment   (Bakali.   Early   sessions initially   proposed   a   two­factor   definition   of   the   thera­ produced   a   strong   member­leader peutic relationship in group: (1) belonging and acceptance positive   bond   while   later   sessions factors   (cohesion   and   member­leader   alliance)   and   (2) included   positive   bonds   with   both interpersonal   work   factors   (group   working   alliance. In describing direction.  Positive bond  described the affective relationship collected   from   counsel­ing  centers   and members felt with their leader (vertical cohesion) and in nonclinical   process   groups   replicating member­to­member   relationships   (horizon­tal   cohesion).   After   item quality  of  the relationship in both nonclinical and clinical consensus   was   achieved.   The   next   study the   emotional   sup­port   the   group   experience   affords(Lorentzen.   2005)   estimated   the pirical   (statistical   fit   with   two­ empirical   overlap   of   four   commonly   used   relationship dimensional model) and clinical criteria measures   by   having   662   members   from   111   different (does   it   provide   actionable   clinical groups complete a copy of each. This study found that a information?) were utilized to produce a two­dimensional model (quality & structure) explained a 40­item   instrument   called   the   Group majority of the common variance across the four measures.   We   also item reduction process to determine if a undertook   a   series   of   studies   to   evaluate   a   toolkit subset of “practice friendly” items could containing   several   relationship   measures   (Strauss. structure model while using 30 items. Specifically.   Krogel   &   Burlingame.population in psycho­educational groups members   were   unable   to   dis­tinguish   member­to­group (Krogel.   Both Horizontal   cohesion   describes   a   group   member’sdimensions   (relationship   quality   and relationship   with   other   group   members   and   with   the structure) emerged.settings   and   countries.   One   study comprises   the   di­rection   and   function   of   the (Bormann & Strauss.   Baldwin..   data   was groups. Positive work  equally captured the tasks and goals of the while adding a population of seriously group while negative relationship capture empathic failure mentally   ill   inpatients   to   determine   if with   the   leader   and   conflict   in   the   group. Hoglend.   2004).   horizontal   cohesion captures   the   quality   of   member­to­ member   relationships. quality   and   two   structural   factors (Burlingame. positive   work.  and   recent   research   efforts   have   clarified   its dimensional   model   that   varied   by components. In describing function. Germany   and   Switzerland. but unlike the first group­as­a­whole.

Relationship quality Positive bonding relationship Positive working relationship Negative relationship Member­member Affective cohesion—positive Task cohesion Positive working relationship Negative relationship Relationship quality Positive bonding relationship a  cf. . McClendon & Burlingame (in press).

 That was tactless. positive last   group   meeting.   1996)   to   illus­trate   the you. and Susan pats Mary on Leader   to   Steve:   Steve. the   group   and   the   whole   group Meta­ cheers   when   she   enters]. positive bond.   It give [laughs] because I uh.   positive   bond  toward Analytic Review  Method Prior  to  beginning  this meta­analysis   we reviewed the literature for similar   meta­analyses. Leader   to   Susan:   We wanted you to be here so member­group  dimension has  been the   most   elusive   theoreticalbad. and I process. kinda tacky. with   the   group­as­a­ Member­member. [Ascohesiveness within this they   are   talking   Susan   comes   into group.  Member­ was none of you damned business. Three   cohesion   meta­ analyses were located . session   therapy   group   (Burlingame Susan to Steve: Thank &   Barlow. you’d check in with me on that. Steve: I also feel badly that Susan the   group   leader   and another   group   member is not here today. I know we’re notof   a   high   level   of supposed to interact outside. but right now you feel like you’ve In   this   dialogue.   The   followinghere   is   because   I   knew dialogue   includes   all   threeI’d   get   the   reception   I relationship   structures   (member­just got.   what   I relation­ship. uh even though I said itI’m   sorry. [Susan starts to member. I’m notmeans   a   lot   to   me   that handling   it   well. worried.   leader   pats structure   categories   in   Table   1   are Susan   on   the   shoulder identified by italics.   negative [Group   laughs]   But   uh. Steve   to   Susan:   I Steve: I need to apologize to you apologize   for   being because I was a little bit abrupt with abrupt   with   you   last you last week and I thought that wasweek. Clinical  Steve to Susan: Well.  Leader­member.   member­leader.   we got nothing to give— that you’re nosee   Steve   interacting longer   handling   it   well. I have nothing toaccept   your   apology. Leader:   You’ve   done   a   lot   of Member­member.  Member­leader. meant was I’m not handling it well Susan   to   Steve:   It and.  Leader­ with   a   notable   level   of interpersonal   risk   with member. transcript from Session 14 of a 15­positive bond.  Leader­ member.   I   can’t   sharedidn’t   bother   me.   andcry   and   group   laughs member­group).] M ember­member. MCCLENDON. .  good work over the past few monthspositive bond.36 BURLINGAME. positive work. .   the   qual­ity   andlightly. AND ALONSO Susan.   some   of   us   were construct to empirically detect withthinking  that  you  had  a crisis   and   we   were mixed findings from studies.   The   reason   I   tore multidimensional   complexity   ofout of work so fast to get group   cohesion. Steve:   I’ve   been   thinking   aboutwhole   supporting   the her and her crisis a great deal.   therefore. positive bond. Example I’m   glad   you’re   here The   relationship   quality   andbecause   I’ve   been structure   model   (Tables   1a. negative relationship. I miss her.  Group­ member.   1b)worried   about   you provides   a   practice­friendly[Steve goes on to inquire framework   to   recognize   cohesiveabout   Susan’s   situa­ group   behavior. bond.   you   OK?the   knee]  Member­ You  seemed  upset  at   the  end  of  our group/ member. negative relationship probe.   These   types   of almost called you [leader] up to get interactions are evidence her phone number.   We   selected   ation.   but   I anything with you. member.

  frequency   of cohesion   assessment. studies   were   searched Nachitgall. model   based   structure.   and   (e) English   text.506found   to   moderate abstracts   were   retrieved   using   theoutcome   in   previous following   search   terms:   groupgroup   therapy   meta­ psychotherapy.analyzed   for   the cohesion.   & Burlingame et al.   Hoag   &   Burlingame..   2001.   1998). A total of 1.   outcome measure). psychotherapy Burlingame et al.   and   group vari­ables   (manual   vs. article’s   cohesion definition.analyses.using this method.   group   therapy.027 abstracts.   group format.   leader variables   (single   leader vs.   Dissertations   were   not included.. experience.   six of  the most published   group   therapy   meta­ frequently used cohesion analyses to develop inclusion criteria mea­sures (cf.   session length. treatment length. 1991.   the   article   wasrate). Next.  After achieving   this   criterion.   we   relied   upon   five Finally.   member   variables retrieved and again reviewed for fit. Gully. (b) groups meeting for the reference   list   see purpose of counseling.   2003.   treat­ ment   location.   McRob­erts.   Fuhri­man.   heter­ ogeneous. across   the   30   identified 1997.   Thus. time   cohe­sion   was assessed. 2011) Mosier. & Strauss. Lipsey & using   Google   Scholar Wilson.73).   group   cohesion.   Complete agreement   was   required with   discrepancies resolved by the graduate student. MedLine.   yielding   a must have  included: (a) a  group  that final   data   set   of   40 was   comprised   of   at   least   three studies   (for   full members. yielding 1.   (d)   data   that allowed the calculation of effect sizes as   weighted   correlations. treatment   setting.   co­following   continuous hesiveness. Burlingame. 2009). 1995.   orientation). Mullen & Copper. spanning   four   decades   (Januarymany of which had been 1969– May.   Data   was support   groups. (client   gender.   Burlin­game. but none focused on cohesion reviewed   and   42 in group psychotherapy.   primary diagnosis). Table 1 in herein   (Burlingame.  if publication.   To   be Ten   additional   studies included in our meta­analysis. size).   (c)   at   least   one quan­titative   measure   of   both cohesion   and   outcome. member   variables (gender. and We   selected   and Google   Scholar   for   publicationscoded   24   variables.   and   a   group variable   (group   size). two raters independently coded   each   article contained   in   the   meta­ analysis. (Evans & Dion. 2011). Search Strategy Co din g  an d  An aly sis Articles   were   obtained   by searching PsycINFO. Eachvari­ables:   study abstract   was   reviewed   for   fit   with characteristics   (year   of the  above inclusion  criteria and.   &   Hoag. the reference sections of & Whitney. 2006. homogeneous   vs.   coled   groups. or   personal   growth. settings. obtained   articles   were 1994).   concurrent treatment.   client A total of 24 articles were included age).   attrition deemed   promising. We   also   examined   the following   categorical vari­ables:   Study characteristics  (cohesion measure   definition. and group climate.   group   counseling.   Kosters. Eight   raters   (1 graduate   student   &   7 undergraduate   students) were   trained   via   a codebook to rate articles unrelated   to   the   studies herein   using   an   85% criterion   level   of agreement   with interrater   reliability being  high  (  . . all examined unduplicated   studies cohesion’s   relationship   to   taskwere   identified   and reviewed   resulting   in   6 performance   in   nonthera­peutic studies   being   included. Devine. studies were   added.

 the overall conclu­ sion from 40 studies published across a four­decade span is a positive relation between cohesion and outcome. we examined the degree of heterogeneity (variability among the effect size mean is higher than what would be expected from sampling error.. 1994).533 studies. we averaged these effect sizes (weighted by n) and used this average in subsequent analyses. Past reviewers have concluded that cohesion has shown an overwhelmingly posi­ tive relation with patient improvement (Tschuschke & Dies. k (40).   and   feedback)   but   there   has   been little progress due to the varied definitions and Moderators and Mediators Table 2 Study characteristics Variable Number of studies Year of publication (median) Overall number of clients Average age of clients Average number of sessions Theoretical orientation of group Cognitive/behavioral Psychodynamic/existential Humanistic/interpersonal/supportive Eclectic Unknown1 Primary diagnosis Informal Anxiety disorder Mood disorder Substance disorder Eating disorder Personality disorder Medical condition (not somatic disorder) Unknown Country USA Canada etc (if any) Role of group Only group/group as primary treatment Part of milieu of treatment (e.   self­ disclosure. 1994). 2009).   Our   analysis variables for the cohesion­outcome link (Horn­ of   the   studies sey et al. Results A summary of study characteristics is provided in Table 2.4 23. capturing several classic papers (e. publication bias is unlikely to be a threat to the validity of the study. The plot illustrated the fairly symmetrical data.g.. although over a fourth were published prior to 1990. 2002). Roether & Peters. a “trim and fill” analysis (Duval & Tweedie.. Braaten.   member   accep­tance. 2007). Following calculation of the aggregate correlation. Mediators have been proposed identified (e. Zimerberg. Thus.17 to . Houts. The weighted aggregate correlation (Hedges & Vevea. & Rand.   support.25. Budman et al. studies   examining   moderator   or   mediator2007). 1994. Yalom.5 33 25 20 8 20 13 10 8 3 8 35 13 18 3 5 13 5 18 14 5 7 1 2 5 2 7 10 4 23 68 9 27 15 68 18 6 27 7 3 10 40 05 10 33 1 4 16 2 4 13 38 30 15 20 23 13 45 8 15 12 6 8 9 5 18 3 10 20 20 0 48 3 4 8 8 0 19 1 . thus creating multiple cohesion­outcome correlations from a single study.05) with a 95% confidence interval of .   A   high % N 40 1997. 1989. Eighty percent of the groups had a therapy focus. confounds   with group   cohesion Until recently.018 studies with null effect sizes (no effect) would be needed for inclusion.54 ( p   . Thus. A random effects model was used to determine whether differences in the cohesion­outcome relationship existed across the 24 variables. 2001). 1972. The majority (58%) of studies were published after 2000. 1998. Random effects assume that studies are selected from a population of studies and that variability between studies is the result of sampling error. the effect sizes and their subsequent sample sizes were put into a contour enhanced funnel plot (Begg. 1967). Lipsey & Wilson. N (3.32 which is a medium effect. We thus assessed potential publication bias as a fail­safe N (Begg.37 SPECIAL ISSUE: COHESION IN GROUP THERAPY A number of studies used several outcome and cohesion mea­ sures. This statistic indicated 2. 2000a. medication.. the likelihood of publication bias is improbable.323). This analytic model is recommended as a conservative test (Hedges & Vevea.g.. 1998) was statistically significant r   . there have been few empirical (Hornsey   et   al.7 3. calculated to determine the fictional value of addi­ tional studies needed to render the current results as invalid. Given the initial literature search yielded only 2. Results indicated no studies were missed..g. Burlingame et al. z   6. as heterogeneity allows moderator results to be interpreted with more confidence. which confirmed there were no studies missing from the meta­ analysis. only 43% of the studies posted a statistically significant correlation. Second.. individual therapy) Unknown Setting Inpatient Outpatient Unknown Location University counseling center Clinic or private practice Hospital Community mental health center Classroom setting Unknown Type of outcome measure General psychological distress Depression Anxiety Quality of life/general well being Interpersonal problems/relationships Self esteem Other Unknown1 Number of cohesion measure administrations Once Twice Three times Four times Five or more times Unknown 1  Values don’t add up  to 40 because some  studies used multiples. Finally. 2000b) was conducted to estimate the number of studies the meta­analysis likely missed due to publication bias. Berkeljon & Baldwin.323 36. When this occurred. 1989. The results from our meta­analysis (see Figure 1) differ. Our efforts made to gather unpublished studies were unsuccess­ ful. five   statistically significant moderators   among the   24   coded variables.

  p  .8. .00.  2  .level   of   heterogeneity   was   found   acrossindicating   that studies   [I2  82%.  Q(39)  216.06].moderator   variables can   be   interpreted with confidence.

35 0.34 0.53 0.12 0.21 0.78 0.11 0.24 0.64 0.60 1. members   tended   to   yield   effect   sizes   of Leaders   espousing higher   magnitude   than   studies   withan   interpersonal relatively older group members.56 3.15 0.49 0.28 1. p .26 -0.14 0.21 0.27 1.12 0. reliably related to outcome in both inpatient58)   with   psychody­ and   outpatient   settings   (r  .75 2.18 -0.17 0.36 0.26 0.68 0.15 0.03 -0.19 0.22 0. cohesion wasoutcome relation (r  .21 -0.12 0.19 -0.60 Favors negative relationship Figure 1.28 0.orientation   posted df 1.50 0.03 0.35 0.49 0.67 0.11 -0.19 0.43 0.09 -0.01 0.18 0.25 0.namic   (r  .67 0.00 0.57 0.09 0.00 0.00 0.63.23 0.10 0.18 -0.36 0.36 0.84 0.04 -0. Q 14.05.18 0.20 0.46 0.05.  df  9.61 0.30 0.00 -1.74 1.30 0.51 2.00 0.12 -0.96 0.64 1.38 BURLINGAME.89 0.04 0.23 0.35 -0.02 0.90 2.00 1.01 0.52 0.26 0.0001).25 0.12 -0.42 1.16 -0.06 0.56 0.06 2.63 0.01 0.02 0.30 -0.48 0.39 0.46 0.50 0.37 0.10 0.22 0.43 0.41 9.13 0.01 0.48 1.00 0.61 0.69 1. Theoretical orientation   of   the One   member   characteristic   explained differences   in   the   cohesion­outcome   link.18 0.09 -0.45 1.00 0.54 0.00 0.65 0.42 0.46 0.92 0.00 0.outcome   relation. This finding was not explainedthe highest cohesion­ by client symptom severity.24.02 0.86 2.26 -0.28 0.33 0.63 0.44 1.33 0.19 0.50 0. AND ALONSO Study Name Statistics for each Study Correlation and 95% Cl Andel et al (2003) Antonuccio et al (1987) Beutal et al (2006) Braaten (1989) Budman et al (1989) Crowe & Grenyer (2008) Falloon 1981 Flowers et al (1981) Gillaspy et al (2002) Grabhorn et al (2002) Hilbert et al (2007) Hoberman et al (1988) Hurley (1997) Hurley (1989) Joyce et al (2007) Kipnes et al (2002) Kivlinghan & Lilly (1997) Levenson & Macgowan (2004) Lipman et al (2007) Lorentzen et al (2004) Mackenzie & Tschuschke (1993) Marmarosh et al (2005) Marziali et al (1997) May et al (2008) Norton et al (2008) Oei & Brown (2006) Ogrodniczuk & Piper (2003) Ogrodniczuk et al (2005) Ogrodniczuk (2006) Ra o & Hurley (1995) Rice (2001) Roether & Peters (1972) Rugel & Barry (1990) Ryum et al (2009) Ta et al (2003) Taube-Schiff et al (2007) Tschuschke & Dies (1994) Woody & Adesky (2002) Wright & Duncan (1986) Yalom et al (1967) Effect Lower Upper ZpSize Limit Limit Value Value 0.39 -0.01 0.09 0.56.15 0.15 0.28 0.54 0.  Weighted effect size for cohesion­outcome  relationship.11 0.08 0. respectively).38 2.38 0.22 0.24 -0.   Q Studies   with   relatively   younger   group23.47 0.61 2.  p  .83 2.48 1.90 0.43 0.70 0.00 -0.62 0.28 0.72 0.92.03 0.06 0.91 0.00 0.10 0.25)   and cognitive­behavior (r .45 0.01 0.10 0.75 16.7 0.30 0.72 2.19 0.62 0.04 0.00 0.06 0.29   &   .18) orientations Favors positive relationship .19 0.26 0.05 0.52 0.01 0.12 -0.43 -0.57 0.93 0.00 -0.79 6.05 0.01 0.01 0.74 6.19 -0.39 2. MCCLENDON.30 -0.10 0.00 -0.20 1.  p  .07 0.06 0.leader   produced   a The average age of participants was neg­significant difference atively   associated   with   effect   sizein   the   cohesion­ magnitude within studies (r  .22 0.00 1.64 0.53 0.28 -0.32 0.39 2.

  This argues for cohesion being considered as an evidence­based   relationship   factor   for groups   using   a   cognitive–   behavioral.posting   the   lowest   values.  p  .87. Group characteristics also proved useful in explaining differ­ences in the cohesion­ outcome association.   In   addition.  df  2. psychodynamic.   and   in­terpersonal orientation.  r  . Groups comprised of 5–9   members   in   each   session   posted   the strongest   cohesion­outcome   relationship (r  .05.88.   eclectic).21)   or   no   reliable relationship   (behavioral.35)   whereas   groups   of   any   other   size (fewer   than   5   members   present   or   more than   9   members)   were   much   weaker   (r  .  Q  6.  df  2.  p  . Groups lasting 12 or more sessions posted .05.  Q  4. 16). significant   differences   were   found   by number   of   sessions.   The   remaining orientations posted either statistical trends (humanistic.

  Could   a member’s   interpersonal style   explain   past   mixed cohesion­outcome findings?   Unfortunately. theme. These two studiesmore   when   their also   contributed   to   a   significantcohesion   decreased difference   for   type   of   group   whereduring therapy.03. andthe life of the group were group   time   appeared   to   beassociated   with   greater principally focused on this commonsymptom   improvement.75. However. df 4. df 1. Studies2010).most   when   their experience   of   cohesion 23).   itstionship presence would likely be diminishedcohesion   and   outcome and perhaps attenuate its relationshipwith  73 depressed  Ger­   inpatients with outcome.61)   producedhostile   interpersonal larger   cohesion­outcomeproblems   improved relationships than therapy groups (r .   Kivlighan   &   Lilly. Ifinterpersonal   style group   cohesion   is   undervalued   ormoderated   the   rela­   between neglected   by   a   group   leader.56)   andpatients   with   cold   or analog   groups   (r  .05.21.05. the   “jury   is   out”   on   this question   since   the primary   measure assessing   cohesion   in both .   &   Strack.18).  Qfriendly”   improved 14. Q 12. cohesion as a therapeutic strategy.62 and  r  . the .38 and r greatest improvement. The value of this meta­analytic   review   parame­ters—study is that it offers one theory­driven explanation of   both   the   positive   and neutral   relationship findings   in   this   meta­ analysis. Kivlighan A recent replication of &   Lilly.21. The two studies thatman described   procedures   for   enhancing(Schauenburg.   1989. (Hurley.patient   moderator 2004)   have   suggested   that   the   bestvariable   that   was   not test of the cohesion­outcome relationincluded   in   our   meta­ would   be   to   examine   studies   thatanalysis. a third significantoriented inpatient psycho­ group   variable   (group   focus)therapy   unit   in   Germany partially   supported   these   two(Dinger   &   Schauenburg. respectively. Q 4. opposite was evi­dent for those   who   described Other Potential Moderators themselves   as   too Two  studies  that  fell  outside  ourfriendly. p .   Sammet. p . findings. two studies (Hurley. 1994.   Interactivedescribed   themselves   as groups   posted   a   higher   cohesion­too   cold   and   who outcome   correlation   than   problemreported   increased cohesion   posted   the specific groups (r .   In   the   first   members’ emphasized   the   importance   ofstudy. Our initial reaction was to dismissin­creased   during   the these   reliable   differences   since   thegroup.   Higher   levels   of coded  as  problem  specific  includedcohesion   as   well   as   an groups   that   were   comprised   ofincrease in cohesion over members with similar diagnoses.   Once interactive and group time appearedagain   patients   who to   be   less   structured. Burlingame et al. whereas personal   growth   task   (r  . 1989. p .   we   (Fuhriman   &they suggest a potential Burlingame.05).   with 1997) produced a cohesion­outcomepatients interpersonal   problems correlation   that   was   approximately three times larger than those that diddescribed   as   “too not (r  .   1997)   used   studentsthat   study   involved   327 participating   in   interpersonalmixed   diagnosis   adults experiential   groups   that   can   betreated   on   a considerably   different   from   therapypsychodynamically groups. respectively).39 SPECIAL ISSUE: COHESION IN GROUP THERAPY because   they   were higher   cohesion­outcomerecently   published   or correlations  than  did  groups  lastingthe   text   in   Ger­man— are   raised   herein   since fewer than 12 sessions (r . df 1.   Studies  coded  as  interactivereplicating the findings of had   members   who   were   moreour   meta­analysis.   Specifically.27. In   the   past.2001). cohesion   in   their   methods   sectionRabung..

  these   studies cohesion’s   relation   with   treatmentwere   not   based   on outcome.   irrespective of   theoretical orientation.   the   question in   definition   and   measurement.   The   meta­formal   mental   health analysis   clarifies   this   confusion   by diagnosis. but is strongest when a group lasts more than 12 sessions   and   is comprised   of   five   to nine members.25)   with actions   among   different   diagnoses.   thus   attenuating   ourstudies   included   herein.   When } Cohesion is reliably one   considers   the   possible   inter­associated   (r . Limitations of the Research There   are   too   few Four limitations exist in the general studies   to   adequately cohesion   literature. as pointed out been   the   mixed   findings   regardingabove. that   intentionally   used group.correlational   studies.   “what”   (are   weinterventions to enhance getting   work   done?).   also   limiting   the test   for   potential generalizability   of   our   meta­analysis.   post   higher cohesion­outcome   links than groups less focused on   process.   and   leader).   It   suggests   that   leaders the finding from studies pay   attention   to   the   “who”   (member. psychodynamic.interactions between the The   first   chal­lenge   to   understanding characteristics and utilizing cohesion as an evidence­ examined.   theoretical   orientations. valence)   of   group   relationships.   and   “how”cohesion that resulted in (positive   and   negative   emotionala   stronger   cohesion­   relation.   Aoutcome second   challenge   in  the  literature   has However.   it   is important   to   encourage member interaction.   Some   studies   support   itsgroups   comprised   of relationship with outcome while othersmembers   having   a show   no   association. pointing   out   differ­ences   between measures. the moderators found herein may further explain past mixed results. parsimonious.  } Younger   group members experience the largest outcome changes when   cohesion   is present   within   their groups. Fostering  .   and   group   focus.   orientations.   or cognitive–   behavioral orientation.   Theof   causality   cannot   be two­dimensional   model   (structure   &addressed   in   these quality)   offers   a   prom­ising.  } Cohesion   explains outcome   regardless   of the length of the group.   Thus.   This association   was   found for   groups   across different   settings (inpatient   &   outpatient) and   diagnostic classifications.   and   type   ofoutcome   is   defined   as reduction   in   symptom distress or improvement in   interpersonal functioning. based principle has been the variability Fourth.  the  heterogeneity of  studysupported  by our  meta­ characteristics   present   in   meta­analysis: analyses   creates   difficulty. considerable   caution must   be   invoked   in interpreting   results. We see the following therapeutic   practices Third. Cohesion requires   sufficient member   interaction  and time to build.   and   empirically   based Perhaps   the   strongest definition   of   the   latent   structureevidence   to   support   a inherent   in   measures   of   groupcausal   relationship   was relationship.studies   fall   short   on   psychometricgroups   among   the   40 support.Therapeutic  group   length.Practices Moreover.  } Group   leaders emphasizing   member interaction.  } Cohesion   is   most strongly   involved   with patient   improvement in groups   using   an interpersonal.group   outcome when settings. confidence in its conclusions.

Psychotherapy } Cohesion   contributes   to   groupInterventions   Rating outcome   across   different   set­tingsScale. 2006). we would point toverbal   interaction. AND ALONSO in   Table   3.   and therapist behaviors that can enhanceemotional   climate group   cohesion.   Thus. MCCLENDON.   A   recent   North Table 3   study Group Psychotherapy Intervention  American (Chapman. & Duivenvoorden.  GPIRS)   developed (inpatient   &   outpatient)   andfrom   interventions diagnostic   classifications.  group   structure.40 BURLINGAME. In this regard.   allsuggested   in   our   first group   leaders   should   activelycohesion   chap­ter engage   in   interventions   that(Burlingame et al.   De cohesion­outcome   relationship   inGroot. Rating Scale (GPIRS) Thayer. their groups.  Baker.. 2010) translated the Dutch GPIRS   into   English   and replicated   these   findings. 2002).   These cohesion will be particularly usefulbehaviors   track   nicely for   those   working   in   collegeonto   a   behavioral   rating counseling   centers   and   withscale   (Group adolescent populations.   These   specificinterventions   were interventions are depicted positively   correlated   with member­reported   co­ hesion.In two  studies  (Sternberg Leaders   which   purposefully   try   to&   Trijs­burg.  Porter.   2005.   Trijsburg. enhance   cohesion   have   a   strongerSnijders.   &   Burlingame. cultivate   and   maintain   cohesion. Small­to­moderate correla­ .

 attacked. T. or disconnected Involved members in describing and resolving conflict (instead of avoiding conflict) Elicited verbal expressions of support among group members Encouraged members to respond to other members’ emotional expression (such as acceptance. & Kaul. participation) Identified and discussed fears/concerns regarding self disclosure Structured exercises that focus on emotional expression and exchange Discussed member roles and responsibility Discussed leader roles and responsibility Verbal interaction Modeled giving personal information in the “here and now” Modeled appropriate member­member behavior Modeled appropriate self disclosure Modeled appropriate feeling disclosure Maintained moderate control Facilitated appropriate member­member interaction Encouraged self disclosure without “forcing it” Encouraged self disclosure relevant to the current group agenda Helped members understand that disclosed issues achieve more resolution than undisclosed issues Encouraged here­and­now vs. misunderstood.   Leader   interven­tionsrecommend behaviors in Table 3 to facilitating   structure. belonging. replicating  the  Dutch  findings  on  a different measure of cohesion..   we   the cohesion. absences. E. confidentiality. Garfield & A. 332–343.Setting treatment expectation Establishing group procedures Role preparation Verbal style and interaction Self disclosure Feedback Leader contribution Member contribution Group structuring Set group agendas (such as discussion topics or group activities) Described rationale underlying treatment Discussed group rules (such as time. 19. Re fer en ce s Bakali. & Lorentzen. S.   (1978). Handbook   of psychotherapy   and . L. story­telling disclosure Interrupted ill­timed or excessive member disclosure Elicited member­member feeling disclosure (versus informational disclosures) Leader shared relevant personal experience from outside of therapy (without being judgmental or overly­intellectual) Reframed injurious feedback (interrupting. L.   (2009).   and   the emotional   climate.   Experiential group   research: Current   perspectives. Bednar. empathy) 41 SPECIAL ISSUE: COHESION IN GROUP THERAPY Cohesion   is tions  were  found  with  each  GPIRSintegrally related to the subscale.   manage  verbalresearch   has   identified interaction  and   maintain  group specific   behaviors   that structure  were   moderately   corre­enhance   cohesion.   suggesting   that   leadersuccess   of   group interventions   intended   to   affecttherapy.   Bergin   (Eds. Psychotherapy   Re­ search..). J. Baldwin. interaction were positively related to cohesion   and   negatively   related   to interpersonal   distrust   and   conflict.   S. tardiness. if necessary) Restated corrective feedback by member Used consensus to reinforce feedback (toward therapist or group member) Balanced positive and corrective leader­to­member feedback Encouraged positive feedback Gave structured feedback exercise Helped balance positive and corrective member­to­member feedback Therapist helped members apply in­group feedback to out­of­group situations Creating and maintaining a therapeutic emotional climate Maintained balance in expressions of emotional support and confrontation Showed understanding of the members and their concerns Refrained from conveying personal feelings of hostility and anger in response to negative member behavior Leader was not defensive when interventions failed Leader was not defensive when confronted by a member Maintained an active engagement with the group and its work Used nonjudgmental language with members Modeled expressions of open and genuine warmth Encouraged active emotional engagement between group members Fostered a climate of both support and challenge Responded at an emotional level Developed and/or facilitated relationships with and among group members Helped members recognize why they feel a certain way (identifying underlying concerns or motives) Prevented or stopped attacking and judgmental expressions between members Assisted members in describing their emotions Recognized and responded to the meaning of groups members’ comments Prevented situations in which members felt discounted. R.. J.   For lated with member­reported levels ofthese   reasons.   emotional climate   and   managing   verbalgroup practitioners. Modeling   group process   constructs   at three   stages   in   group psychotherapy. attendance. In S.

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