Psychotherapy 2011 American Psychological Association2011, Vol. 48, No. 1, 34 420033-3204/11/$12.00 DOI: 10.1037/a0022063

Cohesion in Group Therapy

Gary M. Burlingame, Debra Theobald McClendon, and Jennifer AlonsoBrigham 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 cohesionrelationship quality (positive bond, positive work, and negative relationship) and structure factors (member-leader and member-member). To further understand the literature, we conducted a meta-analysis 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, meta-analysis

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 synony-mous 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, member-group, and member-leader. From the perspective of the therapist, relationships include the same three components as well as two additional: leader-group 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 meta-analytic review of cohesions relation with outcome and discuss potential moderators, ending with a tabular summary of therapeutic prac-tices 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

meta-analytic 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, sticking-togetherness) 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 well-being, 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, physical seating distance, amount of eye contact, and the length of time group members engaged in a group hug (Hornsey, Dwyer, & Oei, 2007). The definitional challenges of cohesion are reflected by one teams observation that just about anything that has a positive valence [with outcome] has been interpreted at some point as an index of cohesion (Hornsey, Dwyer, Oei, & Dingle, 2009, p. 272).

After reviewing the literature, we believe the evidence supports two fundamental dimensions of cohesion: relationship structure and rela-tionship quality. We identified nine measures of cohesion that were most frequently studied in the literature and classified each measure by its use of the structural and affective/task definitions of cohesion (see Table 1 in Burlingame, McClendon, & Alonso, 2011). All assess horizontal cohesion between members and their group, while fewer than half focus on a members relationship with the leader (vertical). In a similar manner, affective bond is universally assessed by all measures while the task cohesion is assessed by a third of the mea-sures. Of note is our argument that the use of different measures

34SPECIAL ISSUE: COHESION IN GROUP THERAPY35

would likely produce varied results, even if measuring the same group (Burlingame et al., 2002).

The first dimension of coherence, structure, comprises the di-rection and function of the relationship. In describing direction, vertical cohesion refers to a group members perception of the group leaders competence, genuineness and warmth. Horizontal cohesion describes a group members relationship with other group members and with the group-as-a-whole. In describing function, task cohesion indicates that members are drawn to the group to accomplish a given task or goal, while affective cohesion indicates members feel connected because of the emotional sup-port the group experience affords (Dion, 2000).

The second dimension of cohesion is relationship quality, and recent research efforts have clarified its components. In order to condense the literature and ultimately identify accurate group therapy measures, we initially proposed a two-factor definition of the thera-peutic relationship in group: (1) belonging and acceptance factors (cohesion and member-leader alliance) and (2) interpersonal work factors (group working alliance, individual working alliance, and group climate; Burlingame, Mackenzie, & Strauss, 2004). We also undertook a series of studies to evaluate a toolkit containing several relationship measures (Strauss, Burlingame, & Bormann, 2008). The first study (Johnson, Burlingame, Davies, & Gleave, 2005) estimated the empirical overlap of four commonly used relationship measures by having 662 members from 111 different groups complete a copy of each. This study found that a two-dimensional model (quality & structure) explained a majority of the common variance across the four measures. Specifically, positive bond, positive work, and negative relationship factors explained how members perceived the quality of the relationship in both nonclinical and clinical groups. Positive bond described the affective relationship members felt with their leader (vertical cohesion) and in member-to-member relationships (horizon-tal cohesion). Positive work equally captured the tasks and goals of the group while negative relationship capture empathic failure with the leader and conflict in the group. We found interesting that when examining the structure of the group, members were unable to dis-tinguish member-to-group from member-to-member relationships yielding a two-factor structural dimension: member-leader and member-member.

The three relationship quality factors ( positive bond, positive work, negative relationship) and two structural factors (member-leader and

Table 1 member-member) stimulated subsequent studies that attempted to replicate these findings across clinical settings and countries. One study (Bormann & Strauss, 2007) collected data from 67 inpatient psychodynamic groups drawn from 15 hospitals in Germany and Switzerland. Both dimensions (relationship quality and structure) emerged, but unlike the first study, these authors found support for three structural components (member-member, member-leader, and member-group). The next study (Lorentzen, Hoglend, & Ruud, 2008) tested the same toolkit of measures and reported a similar two-dimensional model that varied by stage of treatment (Bakali, Baldwin, & Lorentzen, 2009). Early sessions produced a strong member-leader positive bond while later sessions included positive bonds with both other members and the group.

Findings from these studies led to an item reduction process to determine if a subset of practice friendly items could be identified from the original measures that contained over 80 items. Both em-pirical (statistical fit with two-dimensional model) and clinical criteria (does it provide actionable clinical information?) were utilized to produce a 40-item instrument called the Group Questionnaire that measured the three quality and structural factors (Burlingame, 2010). After item consensus was achieved, data was collected from counsel-ing centers and nonclinical process groups replicating the first study (Johnson et al., 2005), while adding a population of seriously mentally ill inpatients to determine if the model would be applicable to that population in psycho-educational groups (Krogel, 2009; Krogel & Burlingame, 2009). Using a sample of 485 group members, they found the same two-dimensional relationship quality and structure model while using 30 items.

These studies support structure and quality as the two funda-mental dimensions of cohesion. Following additional studies, we arrived at a 40-item instrument called the Group Questionnaire that measures the three quality and two structural factors (Burlingame, 2010). Table 1a weds the past definition of affective and task cohesion dimensions with the relationship structure and quality model. As can be seen, affective cohesion is split by the emotional valence of the item loading either on the positive bond or negative relationship dimensions. Table 1b depicts how horizontal and vertical cohesion load on the relationship structure dimension. Specifically, horizontal cohesion captures the quality of member-to-member relationships, while vertical cohesion captures the qual-ity of member-to-leader relationships. It is interesting that the

a. Modified framework for understanding cohesion using relationship quality

Relationship structure

Relationship qualityMember-memberMember-leaderMember-groupPositive bonding relationshipAffective cohesionpositive

Positive working relationshipTask cohesion

Negative relationshipAffective cohesionempathic failure & conflict

b. Modified framework for understanding cohesion using relationship structure

Relationship structure

Relationship qualityMember-memberMember-leaderMember-groupPositive bonding relationshipHorizontal cohesionVertical cohesionGroup-as-a-whole cohesion (Climate)aPositive working relationship

Negative relationship

a cf. McClendon & Burlingame (in press).36BURLINGAME, MCCLENDON, AND ALONSO

member-group dimension has been the most elusive theoretical construct to empirically detect with mixed findings from studies.

Clinical Example

The relationship quality and structure model (Tables 1a, 1b) provides a practice-friendly framework to recognize cohesive group behavior. We selected a transcript from Session 14 of a 15-session therapy group (Burlingame & Barlow, 1996) to illus-trate the multidimensional complexity of group cohesion. The following dialogue includes all three relationship structures (member-member, member-leader, and member-group); the qual-ity and structure categories in Table 1 are identified by italics.

Leader to Steve: Steve, you OK? You seemed upset at the end of our last group meeting. Leader-member, negative relationship probe.Steve: I need to apologize to you because I was a little bit abrupt with you last week and I thought that was kinda tacky, uh even though I said it was none of you damned business.

[Group laughs] But uh, what I meant was Im not handling it well and, therefore, I cant share anything with you. I have nothing to give [laughs] because I uh, Im not handling it well. Member-leader, negative relationship.

Leader: Youve done a lot of good work over the past few months but right now you feel like youve got nothing to give that youre no longer handling it well. Leader-member, positive work.

Steve: I also feel badly that Susan is not here today, I miss her.

Member-member, positive bond.

Steve: Ive been thinking about her and her crisis a great deal, and I almost called you [leader] up to get her phone number. I know were not supposed to interact outside. . . [As they are talking Susan comes into the group and the whole group cheers when she enters]. Group-member, positive bond toward Susan.

Leader to Susan: We wanted you to be here so bad, some of us were thinking that you had a crisis and we were worried. Leader-member, positive bond.

Steve to Susan: Well, Im glad youre here because Ive been worried about you [Steve goes on to inquire about Susans situa-tion.] M ember-member, positive bond.

Susan to Steve: Thank you. The reason I tore out of work so fast to get here is because I knew Id get the reception I just got. [Susan starts to cry and group laughs lightly, leader pats Susan on the shoulder and Susan pats Mary on the knee] Member-group/ member, positive bond.

Steve to Susan: I apologize for being abrupt with you last week. That was tactless. Im sorry. Member-member, negative relation-ship.

Susan to Steve: It didnt bother me, but I accept your apology. It means a lot to me that youd check in with me on that.

Member-member, positive bond.

In this dialogue, we see Steve interacting with a notable level of interpersonal risk with the group leader and another group member with the group-as-a-whole supporting the process. These types of interactions are evidence of a high level of cohesiveness within this group.

Meta-Analytic Review Method

Prior to beginning this meta-analysis we reviewed the literature for similar meta-analyses. Three cohesion meta-analyses were located

(Evans & Dion, 1991; Gully, Devine, & Whitney, 1995; Mullen & Copper, 1994), but none focused on cohesion in group psychotherapy; all examined cohesions relationship to task performance in nonthera-peutic settings. Thus, we relied upon five published group therapy meta-analyses to develop inclusion criteria herein (Burlingame, Fuhri-man, & Mosier, 2003; Hoag & Burlingame, 1997; Kosters, Burlin-game, Nachitgall, & Strauss, 2006; Lipsey & Wilson, 2001; McRob-erts, Burlingame, & Hoag, 1998). To be included in our meta-analysis, studies must have included: (a) a group that was comprised of at least three members; (b) groups meeting for the purpose of counseling, psychotherapy or personal growth; (c) at least one quan-titative measure of both cohesion and outcome; (d) data that allowed the calculation of effect sizes as weighted correlations; and (e) English text. Dissertations were not included.

Search Strategy

Articles were obtained by searching PsycINFO, MedLine, and Google Scholar for publications spanning four decades (January 1969 May, 2009). A total of 1,506 abstracts were retrieved using the following search terms: group psychotherapy, group therapy, support groups, group counseling, cohesion, group cohesion, co-hesiveness, and group climate. Each abstract was reviewed for fit with the above inclusion criteria and, if deemed promising, the article was retrieved and again reviewed for fit. A total of 24 articles were included using this method. Next, the reference sections of obtained articles were reviewed and 42 unduplicated studies were identified and reviewed resulting in 6 studies being included. Finally, six of the most frequently used cohesion mea-sures (cf. Table 1 in Burlingame et al., 2011) across the 30 identified studies were searched using Google Scholar yielding 1,027 abstracts. Ten additional studies were added, yielding a final data set of 40 studies (for full reference list see Burlingame et al., 2011).

Coding and Analysis

We selected and coded 24 variables, many of which had been found to moderate outcome in previous group therapy meta-analyses. Data was analyzed for the following continuous vari-ables: study characteristics (year of publication, attrition rate), member variables (client gender, client age), and a group variable (group size). We also examined the following categorical vari-ables: Study characteristics (cohesion measure definition, articles cohesion definition, frequency of cohesion assessment, time cohe-sion was assessed, outcome measure), leader variables (single leader vs. coled groups, experience, orientation), member variables (gender, concurrent treatment, primary diagnosis), and group vari-ables (manual vs. model based structure, homogeneous vs. heter-ogeneous, session length, treatment length, treatment setting, treat-ment location, group format, size).

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 ( .73). After achieving this criterion, two raters independently coded each article contained in the meta-analysis. Complete agreement was required with discrepancies resolved by the graduate student.SPECIAL ISSUE: COHESION IN GROUP THERAPY

37

A number of studies used several outcome and cohesion mea-Table 2

sures, thus creating multiple cohesion-outcome correlations from aStudy characteristics

single study. When this occurred, we averaged these effect sizes

Variable%N

(weighted by n) and used this average in subsequent analyses.

Following calculation of the aggregate correlation, we examinedNumber of studies

40

the degree of heterogeneity (variability among the effect size mean

Year of publication (median)

1997.7

is higher than what would be expected from sampling error;

Overall number of clients

3,323

Berkeljon & Baldwin, 2009), as heterogeneity allows moderatorAverage age of clients

36.4

results to be interpreted with more confidence.Average number of sessions

23.5

A random effects model was used to determine whether differencesTheoretical orientation of group

in the cohesion-outcome relationship existed across the 24 variables.Cognitive/behavioral3313

Psychodynamic/existential2510

Random effects assume that studies are selected from a population of

Humanistic/interpersonal/supportive208

studies and that variability between studies is the result of sampling

Eclectic83

error. This analytic model is recommended as a conservative test

Unknown1208

(Hedges & Vevea, 1998; Lipsey & Wilson, 2001).Primary diagnosis

Informal3514

ResultsAnxiety disorder135

Mood disorder187

A summary of study characteristics is provided in Table 2.Substance disorder31

Eating disorder52

Eighty percent of the groups had a therapy focus. The majority

Personality disorder135

(58%) of studies were published after 2000, although over a fourthMedical condition (not somatic disorder)52

were published prior to 1990, capturing several classic papersUnknown187

(e.g., Braaten, 1989; Budman et al., 1989; Roether & Peters, 1972;Country

USA

Yalom, Houts, Zimerberg, & Rand, 1967). Past reviewers have

Canada

concluded that cohesion has shown an overwhelmingly posi-

etc (if any)

tive relation with patient improvement (Tschuschke & Dies, 1994;Role of group

Burlingame et al., 2002). The results from our meta-analysis (seeOnly group/group as primary treatment104

Part of milieu of treatment (e.g.,

Figure 1) differ; only 43% of the studies posted a statistically

medication, individual therapy)239

significant correlation. The weighted aggregate correlation

Unknown6827

(Hedges & Vevea, 1998) was statistically significant r .25, kSetting

(40), N (3,323), z 6.54 ( p .05) with a 95% confidence intervalInpatient156

of .17 to .32 which is a medium effect. Thus, the overall conclu-Outpatient6827

Unknown187

sion from 40 studies published across a four-decade span is a

Location

positive relation between cohesion and outcome.

University counseling center31

Our efforts made to gather unpublished studies were unsuccess-Clinic or private practice104

ful. We thus assessed potential publication bias as a fail-safe NHospital4016

Community mental health center052

(Begg, 1994), calculated to determine the fictional value of addi-

Classroom setting104

tional studies needed to render the current results as invalid. This

Unknown3313

statistic indicated 2,018 studies with null effect sizes (no effect)Type of outcome measure

would be needed for inclusion. Given the initial literature searchGeneral psychological distress3815

yielded only 2,533 studies, the likelihood of publication bias isDepression3012

Anxiety156

improbable. Second, a trim and fill analysis (Duval & Tweedie,

Quality of life/general well being208

2000a, 2000b) was conducted to estimate the number of studies

Interpersonal problems/relationships239

the meta-analysis likely missed due to publication bias. ResultsSelf esteem135

indicated no studies were missed. Finally, the effect sizes and theirOther4518

Unknown183

subsequent sample sizes were put into a contour enhanced funnel

Number of cohesion measure administrations

plot (Begg, 1994). The plot illustrated the fairly symmetrical data,

Once104

which confirmed there were no studies missing from the meta-Twice208

analysis. Thus, publication bias is unlikely to be a threat to theThree times208

validity of the study.Four times00

Five or more times4819

Unknown31

Moderators and Mediators

Until recently, there have been few empirical studies examining moderator or mediator variables for the cohesion-outcome link (Horn-sey et al., 2007). Mediators have been proposed (e.g., member accep-tance, support, self-disclosure, and feedback) but there has been little progress due to the varied definitions and confounds with group cohesion (Hornsey et al., 2007). Our analysis of the studies identified 1 Values dont add up to 40 because some studies used multiples.

five statistically significant moderators among the 24 coded variables. A high level of heterogeneity was found across studies [I2 82%; Q(39) 216.8, p .00; 2 .06], indicating that moderator variables can be interpreted with confidence.38BURLINGAME, MCCLENDON, AND ALONSO

Study Name

Statistics for each Study

Correlation and 95% Cl

EectLowerUpperZ-p-

SizeLimitLimitValueValue

Andel et al (2003)0.19-0.140.481.150.25

Antonuccio et al (1987)0.00-0.190.190.001.00

Beutal et al (2006)0.230.060.392.680.01

Braaten (1989)0.210.020.382.200.03

Budman et al (1989)0.630.480.746.910.00

Crowe & Grenyer (2008)0.30-0.060.601.630.10

Falloon 19810.16-0.120.421.120.26

Flowers et al (1981)0.560.090.832.280.02

Gillaspy et al (2002)0.19-0.100.451.300.19

Grabhorn et al (2002)0.18-0.110.441.220.22

Hilbert et al (2007)0.240.080.392.840.00

Hoberman et al (1988)0.380.090.612.500.01

Hurley (1997)0.350.280.419.490.00

Hurley (1989)0.700.640.7516.70.00

Joyce et al (2007)0.09-0.100.280.920.36

Kipnes et al (2002)0.00-0.570.570.001.00

Kivlinghan & Lilly (1997)0.360.000.641.960.05

Levenson & Macgowan (2004)0.330.090.542.610.01

Lipman et al (2007)0.15-0.180.450.890.37

Lorentzen et al (2004)0.30-0.330.750.930.35

Mackenzie & Tschuschke (1993)0.46-0.050.781.790.07

Marmarosh et al (2005)0.540.390.676.010.00

Marziali et al (1997)0.19-0.320.620.720.47

May et al (2008)0.180.010.342.060.04

Norton et al (2008)0.300.040.532.210.03

Oei & Brown (2006)-0.04-0.190.12-0.510.61

Ogrodniczuk & Piper (2003)0.220.030.392.280.02

Ogrodniczuk et al (2005)0.22-0.010.431.900.06

Ogrodniczuk (2006)0.420.120.652.690.01

Ra o & Hurley (1995)0.23-0.120.531.280.20

Rice (2001)0.00-0.260.260.001.00

Roether & Peters (1972)-0.18-0.430.10-1.260.21

Rugel & Barry (1990)0.10-0.280.460.500.62

Ryum et al (2009)0.15-0.240.500.740.46

Ta et al (2003)0.18-0.010.361.860.06

Taube-Schi et al (2007)0.430.110.672.560.01

Tschuschke & Dies (1994)0.720.350.903.270.00

Woody & Adesky (2002)0.17-0.120.431.150.25

Wright & Duncan (1986)0.13-0.260.490.640.52

Yalom et al (1967)0.11-0.300.480.520.60

Favors negative relationshipFavors positive relationship

Figure 1. Weighted effect size for cohesion-outcome relationship.

One member characteristic explained differences in the cohesion-outcome link. The average age of participants was neg-atively associated with effect size magnitude within studies (r .63; p .0001). Studies with relatively younger group members tended to yield effect sizes of higher magnitude than studies with relatively older group members; Q 14.92, df 1, p .05. This finding was not explained by client symptom severity; cohesion was reliably related to outcome in both inpatient and outpatient settings (r .29 & .24, respectively).

Theoretical orientation of the leader produced a significant difference in the cohesion-outcome relation; Q 23.56, df 9, p .05. Leaders espousing an interpersonal orientation posted the highest cohesion-outcome relation (r .58) with psychody-namic (r .25) and cognitive-behavior (r .18) orientations

posting the lowest values. The remaining orientations posted either statistical trends (humanistic, r .21) or no reliable relationship (behavioral, eclectic). This argues for cohesion being considered as an evidence-based relationship factor for groups using a cognitive behavioral, psychodynamic, and in-terpersonal orientation.

Group characteristics also proved useful in explaining differ-ences in the cohesion-outcome association. Groups comprised of 59 members in each session posted the strongest cohesion-outcome relationship (r .35) whereas groups of any other size (fewer than 5 members present or more than 9 members) were much weaker (r .16); Q 4.88, df 2, p .05. In addition, significant differences were found by number of sessions; Q 6.87, df 2, p .05. Groups lasting 12 or more sessions postedSPECIAL ISSUE: COHESION IN GROUP THERAPY39

higher cohesion-outcome correlations than did groups lasting fewer than 12 sessions (r .18).

In the past, we (Fuhriman & Burlingame, 1994; Burlingame et al., 2004) have suggested that the best test of the cohesion-outcome relation would be to examine studies that emphasized the importance of cohesion as a therapeutic strategy. If group cohesion is undervalued or neglected by a group leader, its presence would likely be diminished and perhaps attenuate its relationship with outcome. The two studies that described procedures for enhancing cohesion in their methods section (Hurley, 1989; Kivlighan & Lilly, 1997) produced a cohesion-outcome correlation that was approximately three times larger than those that did not (r .62 and r .21, respectively; Q 14.27; df 1, p .05). These two studies also contributed to a significant difference for type of group where personal growth task (r .56) and analog groups (r .61) produced larger cohesion-outcome relationships than therapy groups (r .23); Q 12.03, df 4, p .05.

Our initial reaction was to dismiss these reliable differences since the two studies (Hurley, 1989; Kivlighan & Lilly, 1997) used students participating in interpersonal experiential groups that can be considerably different from therapy groups. However, a third significant group variable (group focus) partially supported these two findings; Q 4.75, df 1, p .05. Studies coded as problem specific included groups that were comprised of members with similar diagnoses, and group time appeared to be principally focused on this common theme. Studies coded as interactive had members who were more interactive and group time appeared to be less structured. Interactive groups posted a higher cohesion-outcome correlation than problem specific groups (r .38 and r

.21, respectively).

Other Potential Moderators

Two studies that fell outside our meta-analytic review parame-ters because they were recently published or the text in Ger-manare raised herein since they suggest a potential patient moderator variable that was not included in our meta-analysis. In the first study, members interpersonal style moderated the rela-tionship between cohesion and outcome with 73 depressed Ger-man inpatients (Schauenburg, Sammet, Rabung, & Strack, 2001). Specifically, patients with interpersonal problems described as too friendly improved more when their cohesion decreased during therapy, whereas patients with cold or hostile interpersonal problems improved most when their experience of cohesion in-creased during the group.

A recent replication of that study involved 327 mixed diagnosis adults treated on a psychodynamically oriented inpatient psycho-therapy unit in Germany (Dinger & Schauenburg, 2010). Higher levels of cohesion as well as an increase in cohesion over the life of the group were associated with greater symptom improvement, replicating the findings of our meta-analysis. Once again patients who described themselves as too cold and who reported increased cohesion posted the greatest improvement; the opposite was evi-dent for those who described themselves as too friendly. The value of this study is that it offers one theory-driven explanation of both the positive and neutral relationship findings in this meta-analysis. Could a members interpersonal style explain past mixed cohesion-outcome findings? Unfortunately, the jury is out on this question since the primary measure assessing cohesion in both studies fall short on psychometric support, thus attenuating our confidence in its conclusions.

Limitations of the Research

Four limitations exist in the general cohesion literature, also limiting the generalizability of our meta-analysis. The first chal-lenge to understanding and utilizing cohesion as an evidence-based principle has been the variability in definition and measurement. The two-dimensional model (structure & quality) offers a prom-ising, parsimonious, and empirically based definition of the latent structure inherent in measures of group relationship. It suggests that leaders pay attention to the who (member, group, and leader), what (are we getting work done?), and how (positive and negative emotional valence) of group relationships. A second challenge in the literature has been the mixed findings regarding cohesions relation with treatment outcome. Some studies support its relationship with outcome while others show no association. The meta-analysis clarifies this confusion by pointing out differ-ences between measures, theoretical orientations, group length, and group focus. Moreover, the moderators found herein may further explain past mixed results.

Third, the heterogeneity of study characteristics present in meta-analyses creates difficulty. When one considers the possible inter-actions among different diagnoses, settings, orientations, and type of groups among the 40 studies included herein, considerable caution must be invoked in interpreting results. There are too few studies to adequately test for potential interactions between the characteristics examined.

Fourth, the question of causality cannot be addressed in these correlational studies. Perhaps the strongest evidence to support a causal relationship was the finding from studies that intentionally used interventions to enhance cohesion that resulted in a stronger cohesion-outcome relation. However, as pointed out above, these studies were not based on groups comprised of members having a formal mental health diagnosis.

Therapeutic Practices

We see the following therapeutic practices supported by our meta-analysis:

} Cohesion is reliably associated (r .25) with group outcome when outcome is defined as reduction in symptom distress or improvement in interpersonal functioning. This association was found for groups across different settings (inpatient & outpatient) and diagnostic classifications.

} Cohesion is most strongly involved with patient improvement in groups using an interpersonal, psychodynamic, or cognitive behavioral orientation.

} Group leaders emphasizing member interaction, irrespective of theoretical orientation, post higher cohesion-outcome links than groups less focused on process. Thus, it is important to encourage member interaction.

} Cohesion explains outcome regardless of the length of the group, but is strongest when a group lasts more than 12 sessions and is comprised of five to nine members. Cohesion requires sufficient member interaction and time to build.

} Younger group members experience the largest outcome changes when cohesion is present within their groups. Fostering 40BURLINGAME, MCCLENDON, AND ALONSO

cohesion will be particularly useful for those working in college counseling centers and with adolescent populations.

} Cohesion contributes to group outcome across different set-tings (inpatient & outpatient) and diagnostic classifications. Thus, all group leaders should actively engage in interventions that cultivate and maintain cohesion. Leaders which purposefully try to enhance cohesion have a stronger cohesion-outcome relationship in their groups.

In this regard, we would point to therapist behaviors that can enhance group cohesion. These specific interventions are depicted

Table 3

Group Psychotherapy Intervention Rating Scale (GPIRS)

in Table 3. These behaviors track nicely onto a behavioral rating scale (Group Psychotherapy Interventions Rating Scale; GPIRS) developed from interventions suggested in our first cohesion chap-ter (Burlingame et al., 2002). In two studies (Sternberg & Trijs-burg, 2005; Snijders, Trijsburg, De Groot, & Duivenvoorden, 2006), group structure, verbal interaction, and emotional climate interventions were positively correlated with member-reported co-hesion. A recent North American study (Chapman, Baker, Porter, Thayer, & Burlingame, 2010) translated the Dutch GPIRS into English and replicated these findings. Small-to-moderate correla-

Group structuringSetting treatment expectationSet group agendas (such as discussion topics or group activities)

Described rationale underlying treatmentEstablishing group proceduresDiscussed group rules (such as time, attendance, absences, tardiness, confidentiality, participation)

Identified and discussed fears/concerns regarding self disclosure

Structured exercises that focus on emotional expression and exchangeRole preparationDiscussed member roles and responsibility

Discussed leader roles and responsibility

Verbal interactionVerbal style and interactionModeled giving personal information in the here and now

Modeled appropriate member-member behavior

Modeled appropriate self disclosure

Modeled appropriate feeling disclosure

Maintained moderate control

Facilitated appropriate member-member interactionSelf disclosureEncouraged 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 here-and-now vs. story-telling disclosure

Interrupted ill-timed or excessive member disclosure

Elicited member-member feeling disclosure (versus informational disclosures)

Leader shared relevant personal experience from outside of therapy (without being judgmental or overly-intellectual)FeedbackReframed injurious feedback (interrupting, if necessary)

Restated corrective feedback by member

Used consensus to reinforce feedback (toward therapist or group member)

Balanced positive and corrective leader-to-member feedback

Encouraged positive feedback

Gave structured feedback exercise

Helped balance positive and corrective member-to-member feedback

Therapist helped members apply in-group feedback to out-of-group situations

Creating and maintaining a therapeutic emotional climateLeader contributionMaintained 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)Member contributionPrevented 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, misunderstood, attacked, 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, belonging, empathy)

SPECIAL ISSUE: COHESION IN GROUP THERAPY41

tions were found with each GPIRS subscale, suggesting that leader interventions intended to affect emotional climate, manage verbal interaction and maintain group structure were moderately corre-lated with member-reported levels of cohesion. Leader interven-tions facilitating structure, emotional climate and managing verbal interaction were positively related to cohesion and negatively related to interpersonal distrust and conflict, replicating the Dutch findings on a different measure of cohesion.

Cohesion is integrally related to the success of group therapy, and the research has identified specific behaviors that enhance cohesion. For these reasons, we recommend the behaviors in Table 3 to group practitioners.

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Received August 19, 2010

Revision received September 14, 2010

Accepted September 14, 2010