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MacNair Semands, 2011
MacNair Semands, 2011
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Abstract
This study examined the factor structure and validity of the Therapeutic Factors
Inventory-Short Form (TFI-S), a measure originally developed to assess Yalom’s
eleven conceptually derived therapeutic factors. Patients in a group-oriented day
treatment program (n= 174) completed the TFI-S and other measures to assess
concurrent and predictive validity. Four broad therapeutic factors were identified:
Instillation of Hope, Secure Emotional Expression, Awareness of Interpersonal
Impact, and Social Learning. Alpha coefficients ranged from .71 to .91. Signifi-
cant correlations between the TFI-S factors and Group Climate Questionnaire
subscales provided preliminary evidence for the concurrent validity of the TFI-
S. Significant relationships were also identified between the TFI-S factors and
improvement in symptoms, quality of life, and interpersonal distress at the end of
treatment, suggesting that the TFI-S may have predictive validity.
THERAPEUTIC FACTORS
245
246 THERAPEUTIC FACTOR INVENTORY
Yalom notes that although he discusses the TFs singly, the distinc-
tions among the factors are arbitrary and they neither occur, nor
function, separately (Yalom & Leszcz, 2005). Many authors have
argued that there is much overlap among the TFs (Fuhriman et
al., 1986; Lese & MacNair-Semands, 2000; MacNair-Semands &
Lese, 2000; Tschuschke & Dies, 1994). This suggests that a higher-
order differentiation of TFs may be useful. It has previously been
observed that group research often defines one aspect of process
in isolation, work that teaches us little about the interrelatedness
of variables (Fuhriman & Burlingame, 1994). Instead, studying
the complex and interrelated nature of factors impacting group
process may provide us with more meaningful results (Kivlighan
& Lilly, 1997; McGrath, 1997). The purported overlap among
TFs has not necessarily implied that the concepts are meaning-
less, but that some of the factors are less meaningful in isolation
and may represent facets of more global (higher-order) TFs.
Findings from research on group processes have suggested
there may be only a few global dimensions underlying the TFs
(Sexton, 1993). Some of the “common factors” that have been im-
plicated include expressed emotion (Castonguay, Pincus, Agras,
MACNAR-SEMANDS ET AL. 247
Purpose of Study
Method
Setting
The study took place in the day treatment program (DTP), one
component of the Psychodynamic Psychiatry Service of the De-
partment of Psychiatry, University of Alberta Hospital, in Ed-
monton, Alberta. The DTP is an 18-week, time-limited, intensive
milieu treatment for patients with affective and personality disor-
ders or maladaptive personality traits. It does not admit patients
with other serious mental illnesses such as schizophrenia. Treat-
ment and rehabilitation in a variety of groups constitute the total
experience of the program for all patients. The pervasive treat-
ment philosophy is psychodynamic; this orientation is bolstered
considerably by systems theory, group theory, and a modification
of ideals formulated for the administration of therapeutic com-
munities (Piper et al., 1996). Consideration of the program as
a total system that supports the application of group therapy is
central.
The treatment team consists of five therapists (from the dis-
ciplines of nursing, social work, occupational therapy, and psy-
chology), a teacher, a psychiatrist, and an administrative assistant.
The psychiatrist shares leadership of the program with the oc-
cupational therapist. The whole team meets daily from Monday
to Friday.
All patients are expected to attend all day, five days a week, for
18 weeks. The average daily census is 30 to 35 patients. Two or
three patients are admitted and a similar number are discharged
each week. The new patients enter ongoing groups within the
program. Treatment consists of a variety of small and large
groups and psychopharmacology. Groups are divided into two
broad categories: psychotherapeutic insight-oriented groups and
rehabilitative sociotherapy groups.
This study focuses on one particular group within the DTP: the
self-awareness group. This small, twice-weekly group (which typi-
cally consists of about 8 patients) occurs during the first phase
of the DTP (between weeks 1 and 6). The self-awareness group
is an introduction to insight-oriented work. The therapist gently
MACNAR-SEMANDS ET AL. 253
Participants
The sample for the present study consisted of 174 patients (65%
female) who were consecutively admitted to the DTP. A thorough
diagnostic assessment was conducted shortly after each patient
was confirmed as appropriate for the DTP. Axis I diagnoses were
determined by the computer-administered Structured Clinical In-
terview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1997) and
validated by the independent clinical diagnosis assigned jointly
by the DTP therapist and psychiatrist, both of whom saw the pa-
tient for the initial program intake. Axis II personality disorder
diagnoses were determined by the Structured Clinical Interview
for DSM-IV Personality Questionnaire (SCID-II-PQ) (First, Gib-
bons, Williams, Spitzer, & Benjamin, 1998) and the Structured
Clinical Interview for DSM-IV Personality Disorders (CAS-II)
(First et al., 1997). Seventy-one percent of the patients received at
least one Axis II diagnosis. The three most prevalent personality
disorder (PD) diagnoses were Avoidant (38%), Borderline (36%),
and Obsessive-Compulsive (22%). Ninety-four percent of the sam-
ple was diagnosed with an Axis I disorder. The most prevalent
Axis I disorders were Major Depression (70%) and Dysthymia
(20%). At admission, patients had a mean age of 37.2 years (SD
= 10.7). Thirty-six percent were living with a partner, 39% were
living alone, and 25% indicated other living arrangements. Sev-
enteen percent had less than a high school education, 20% had
a high school education only, and 64% were educated beyond
high school (trades training, college, or university). Sixty-seven
percent had received psychiatric treatment in the past, and 27%
had been previously hospitalized for psychiatric difficulties. Of
the patients who provided information about ethnic background,
91% were Caucasian, and the remaining 9% were Asian, East In-
254 THERAPEUTIC FACTOR INVENTORY
dian, First Nations, and Hispanic. The dropout rate for the study
was 37.4%.
Measures
item from this subscale is, “The members have felt what was hap-
pening was important and there has been a sense of participa-
tion.” Avoidance pertains to the reluctance of group members
to take responsibility for psychological change. An example of
an item from this subscale is, “The members have avoided look-
ing at important issues going on between themselves.” Conflict
suggests the presence of interpersonal friction. An example of
an item from this subscale is, “There has been friction and an-
ger between the members.” Internal consistency of the GCQ-S
subscales has been high, with alpha coefficients ranging from .88
to .94 (Kivlighan & Goldfine, 1991). The validity of the GCQ-S
has also been established in a number of studies. Ratings on the
GCQ-S have been found to differentiate different types of group
therapy (Joyce, Azim, & Morin, 1988), group therapies of vary-
ing duration (Kanas et al., 1989), and different patient samples
(Daroff, 1996).
Quality of Life Inventory. The Quality of Life Inventory (QOLI;
Frisch et al., 1992) is a self-report measure that assesses 17 areas
of life deemed potentially relevant to overall quality of life. A
subscale score is derived for each domain. Scores are computed
by multiplying the importance rating (0 = not important, 1 = im-
portant, 2 = extremely important) by the satisfaction rating (−3 =
not at all satisfied to 3 = very satisfied). A total scale score is ob-
tained by averaging all subscale scores for domains rated either
important or extremely important (domains rated not important
are excluded from the total score calculation, but these scores
are considered 0 for the subscale scores). Thus, the QOLI total
score reflects subjective well-being in life domains considered to
be of at least some importance to the individual. Examples of
items from the QOLI are: “How important is health to your hap-
piness?” and “How satisfied are you with your health?” The QOLI
has test-retest reliability of .80 to .91 and correlates with other
measures of well-being (Frisch, 1994; Frisch et al, 1992). Internal
consistency is also high (Cronbach’s alpha = .90) (Petry, Alessi, &
Hanson, 2007).
Social Adjustment Scale–Self Report. Social adjustment was as-
sessed using the self-report version of the Social Adjustment
Scale (SAS; Weissman & Bothwell, 1976). The scale consists of 54
questions covering social functioning in 7 areas: (1) as a worker
256 THERAPEUTIC FACTOR INVENTORY
Procedure
Approach to Analysis
at the same time, but we are not aware of methods to correct for
these nesting effects in groups with a rolling membership.
Results
41.Even though we have differences, our group feels secure to me. (Cohe- .17 .58 .04 -.08 4.94 1.51
siveness)
20.I feel a sense of belonging in this group.(Cohesiveness) .32 .56 -.13 .06 4.99 1.42
35.It touches me that people in the group are caring for each other. -.05 .54 .03 .21 4.85 1.63
(Altruism)
33.In group, the members are more alike than different from each other. .28 .40 .04 .18 4.97 1.36
(Universality)
Awareness of Relational Impact
40. By getting feedback from members and facilitators, I’ve learned a lot -.21 .05 .83 -.05 5.22 1.40
about my impact on other people. (Interpersonal Learning)
28.In group, I’ve really seen the social impact my family has had on my .15 -.18 .75 .20 5.57 1.36
life. (Recapitulation of the Family System)
29.Group has shown me the importance of other people in my life. (Inter- .36 -.10 .50 .00 5.35 1.40
personal Learning)
30. I pay attention to how others handle difficult situations in my group .23 .07 .45 .06 5.09 1.30
so I can apply these strategies in my own life. (Imitative Behavior)
43. It’s surprising, but despite needing support from my family, I’ve also .26 .20 .48 -.07 4.64 1.51
learned to be more self-sufficient. (Existential Factors)
37.I find myself thinking about my family a surprising amount in group. -.03 .06 .39 .29 5.29 1.50
(Recapitulation of the Family System)
Social Learning
17. Sometimes I notice in group that I have the same reactions or feelings -.20 .08 .01 .82 4.68 1.75
as I did with my sister, brother, or a parent in my family. (Recapitula-
tion of the Family System)
MACNAR-SEMANDS ET AL.
18. My group is kind of like a piece of the larger world I live in; I see the -.01 .18 -.01 .74 4.80 1.54
same patterns, and working them out in group helps me work them out
in my outside life. (Interpersonal Learning)
19.In group sometimes I learn by watching and later imitating what hap- -.06 -.28 .21 .64 4.10 1.61
pens. (Imitative Behavior)
2. Because I’ve got a lot in common with other group members, I’m start- .20 .02 -.20 .49 4.76 1.60
ing to think that I may have something in common with people outside
the group too. (Universality)
Note.Yalom’s therapeutic factor that each original TFI item was designated to measure is in parenthesis following the item content.
263
264 THERAPEUTIC FACTOR INVENTORY
The alpha coefficients were .91 (factor 1), .86 (factor 2), .82 (factor
3), and .71 (factor 4), indicating high internal consistency among
the items of each factor. In no case did the alpha coefficient in-
crease for any factor with the removal of any one of its items.
This suggests that there were no weak items on any factor.
Concurrent Validity
Each of the four factors from the TFI-S was found to be signifi-
cantly associated with the Engagement subscale from the GCQ-S
(see Table 3). As shown in Table 3, the correlations were small
to moderate, and all in the direction of a positive relationship.
Higher ratings of an engaged group climate were thus associated
with higher ratings of Instillation of Hope, Secure Emotional Ex-
pression, Awareness of Relational Impact, and Social Learning.
We also found a significant inverse association between factor 2,
Secure Emotional Expression, and the Avoidance subscale of the
GCQ-S.
Predictive Validity
Discussion
Our hypothesis was that the factor structure of the TFI-S would
reflect fewer global dimensions of the therapeutic process than
the 11 distinct therapeutic factors seminally conceptualized by
Yalom (Yalom & Leszcz, 2005). In line with this prediction, we
identified four broad factors that accounted for the ratings on
the TFI-S; these factors were labeled Instillation of Hope, Secure
Emotional Expression, Awareness of Relational Impact, and So-
cial Learning. The four identified factors shared only moderate
amounts of variance, indicating that they were not overly redun-
dant. We also found preliminary evidence for the concurrent va-
lidity of the four factors; each of the factors was significantly as-
sociated with Engagement on the GCQ-S, and Secure Emotional
Expression was inversely associated with the Avoidance scale on
the GCQ-S. In addition, the predictive validity of the TFI-S was
suggested by significant associations between the four TFI-S fac-
tors and changes in quality of life, psychiatric symptoms, and in-
terpersonal distress following treatment completion.
Factor Structure
Concurrent Validity
Predictive Validity
sible that the TFI-S factors were more relevant to changes in the
quality of a member’s interpersonal relationships, as measured
by the IIP, than to changes in a member’s performance in specific
social roles, such as employment, as measured by the SAS. Shifts
in specific tasks associated with, for example, partner or parent-
ing roles may take longer for the group member to make follow-
ing group therapy and require continued learning with feedback
from others. The regression findings provide further evidence
suggesting that specific TFI-S factors are associated with change
on QOL and symptoms, and that all four factors may be perti-
nent to change on interpersonal distress. However, these findings
need to receive replication to have confidence in the predictive
strength of the factors.
Overall, the present results are consistent with previous re-
search that demonstrated connections between therapeutic fac-
tors and outcomes (Johnson et al., 2005; Lieberman, Yalom, &
Miles, 1973; Ogrodniczuk & Piper, 2003; Tschuschke & Dies,
1994). MacKenzie and Tschuschke (1993) found that members
who reported higher levels of cohesiveness, acceptance and sup-
port in group experienced greater symptomatic improvement.
Interpersonal definitions of cohesion that focus on interactions
between group members have also been linked to symptomatic
improvement, particularly when they occur in the early phases of
group sessions (Budman et al., 1989). MacKenzie (1983) and Kiv-
lighan and Tarrant (2001) additionally suggested that the group
climate, particularly group engagement, has an important influ-
ence on the outcome of treatment.
Whereas the four factors found in this study represent com-
ponents of the group process, by no means do they capture all
phenomena occurring in therapy groups. While not intending
to be fully comprehensive of all group processes, we want to ac-
knowledge that other features of group process that are in the
literature are not represented by our factors. For instance, John-
son and colleagues (2005) put forth a classification of three fac-
tors: negative relationship factors, positive bonding, and positive
working relationships. Using Yalom’s TF framework, negative re-
lationship factors and other concepts (e.g., conflict) were clearly
not included. Thus, the derived dimensions using Yalom’s clas-
sification are self-limiting from a clinical-theoretical perspective.
274 THERAPEUTIC FACTOR INVENTORY
Conclusion
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280 THERAPEUTIC FACTOR INVENTORY