Components of Group Processes: Have They Contributed to the Outcome of Mood and Anxiety Disorder Patients in a Group Cognitive-Behaviour

Therapy Program?
TIAN P.S. OEI, Ph.D.*# ALANA BROWNE, BBSC"
The present study assessed the influence of group processes on clinical outcomes of patients with anxiety and depression following group Cognitive Behavior Therapy (CBT). Five group environment variables were measured: cohesion, leader support, expressiveness, independence, and self-discovery. One hundred and sixty two patients attended a group CBT program and were assessed at pre and post-treatment. Results provided evidence for the effectiveness of group therapy as patients reported significantly lower depression and anxiety at the conclusion of treatment. Expressiveness was the only predictor of post-treatment anxiety, whereas leader support, expressiveness, and independence were significant predictors of post-treatment depression. Overall, findings suggest that the patients benefited from high levels of expressiveness and independence within their therapy group. In contrast, they failed to benefit from high levels of leader support, whereas both group cohesion and self-discovery appeared to be unrelated to outcome. Cognitive Behaviour Therapy was originally developed as an individual therapy; however, there has recently been a shift towards the application of group CBT because it is time and cost effective (Kwon & Oei, 2003; Morrison, 2001; Oei & Dingle, 2002; Tucker & Oei, 2005). Recent empirical reports document a substantial number of controlled studies demonstrating the effectiveness of group CBT for a broad range of mood
School of Psychology* and CBT Unit, Toowong Private Hospital* The University of Queensland, Brisbane, Australia, 4072 * Mailing address: Prof. OEI, Director, CBT Unit, Toowong Private Hospital, e-mail: oei@psy.uq.edu.au
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 60, No. 1, 2006

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(Clark, Rohde, Lewinsohn, Hops & Seeley, 1999; Oei & Yeoh, 1999; Scott & Stradling, 1990), and anxiety disorders (Hope & Heimberg, 1993; Telch, Lucas, Schmidt, Hanna, Jaimez & Lucas, 1993; White & Keenan, 1990; Van Noppen, Pato, Marsland & Rassmusen, 1998). It is now well established that group treatments are not only time and cost effective, but are also associated with clinically significant improvements for patients with depression and anxiety (Oei, Llamas, & DeviUy, 1999; Oei &L Free, 1995). For example. Van Noppen et al. (1998) found that patients with obsessive compulsive disorder (OCD) who received group treatment had significantly lower scores on OCD measures at post-treatment. Further, these scores continued to decrease up to two years later. The primary focus for current research however, is not on whether CBT is effective but why CBT, and in particular group CBT, is effective. Van Noppen et al, argue that group treatments offer advantages over traditional therapies in that the universality (disclosure of symptoms with other patients decreases stigma and isolation), altruism (helping others), and competition (contracts among patients to achieve their goals) can help to encourage and maintain change. The focus of research has shifted from assessing the efficacy and effectiveness of CBT to investigating the actual change mechanisms at work in both individual and group psychotherapy (Bednar & Kaul, 1994; Casey, Oei & Newcombe, 2004; Furlong & Oei, 2002; Hornsey, Dwyer & Oei, 2005; Kwon & Oei, 2003; Oei & Yeoh, 1999). Considerable debate exists as to the relative impact of specific (i.e., techniques adopted by the therapist) and non-specific (i.e., aspects of the therapeutic relationship not restricted to one particular theoretical orientation) therapeutic elements on treatment outcome (Oei & Green, 2006; Oei & Shuttlewood, 1996). Research indicates that both specific and non-specific factors in therapy produce equivalent improvements in client outcomes, regardless of form or orientation (Brown, 1987; Horvath & Bedi, 2002; Luborsky, Singer & Luborsky, 1975; Martin, Garske & Davis, 2000; Oei & Green, 2006; Oei & Shuttlewood, 1996, 1997; Smith & Glass, 1977; Stiles, Shapiro & Elliott, 1986). Recent meta-analyses addressing the relationship between outcome and therapeutic techniques have demonstrated the equivalence of bonafide therapies (see, for example, Luborsky, Rosenthal, Diguer, Andrusyna, Berman, Levitt, Seligman et al., 2002; Grissom, 1996; Wampold, Mondin, Moody, Stich, Benson & Ahn, 1997). However, Ahn and Wampold (2001) recently conducted a metaanalysis comparing treatments that included or excluded specific tech54

Contribution of Group Processes

niques, which are believed to be theoretically beneficial and necessary for improvement. The results revealed that the inclusion of specific components was unrelated to outcome. Similarly, Castonguay, Goldfried, Wiser, Raue and Hayes (1996) reported that group alliance predicted outcome improvement, whereas an element specific to cognitive therapy for depression actually predicted poorer outcome. These findings have led to speculation that nonspecific factors are more active in bringing about positive change than specific elements. In fact, the latter may have little relevance to outcome (Brown, 1987; Luborsky et al., 1975; Frank, 1971; Frank & Frank, 1991; Messner & Wampold, 2002). In a group setting, patients interact with both the therapist and other group members and additional factors are introduced that are likely to impact on patients' outcome (Burlingame, Fuhriman & Johnson, 2002). However, most of the non-specific factors that are active in group CBT have received little attention despite the fact that many researchers and therapists recognize their importance (Brabender, 2002; Corey & Corey, 2002; Lieberman, 1976; Hornsey et al., 2006). It is possible that processes such as group cohesion and leader support, may have a greater impact on patient improvement than specific therapy techniques. A better understanding of how these factors affect outcome would enable researchers and practitioners to enhance the therapeutic experience through group interaction. The purpose of the present study was to identify the group processes that contribute to the outcome of mood and anxiety disorder patients in a group CBT program. In a study investigating the impact of group processes in group psychotherapy. Moos (1984) identified three components as the underlying patterns of social climate and characteristics of growth-promoting environments. These components are 1) relationship dimensions (the extent that people are involved and support one another; 2) personal growth or goal orientation dimensions (the underlying goals towards which a setting is orientated) and 3) system maintenance and change dimensions (the degree of structure, clarity, and openness to change that characterize the setting. Moos (1984) argues that treatment programs that are disorganized, have unclear rules and procedures, and lack peer and staff support have a higher rate of client dropout. He further suggests that patients tend to do better in programs when they have high expectations for independence and open sharing of personal problems in an involving and expressive environment (Cronkite, Moos & Finney, 1983). Further, the more intensive, committed, and socially integrated a setting is, the greater its 55

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potential impact, particularly on personal factors undergoing developmental change (Moos, 1984). The construct of the therapeutic alliance has received notable attention in the literature and is a widely researched process variable in individual psychotherapy. Therapeutic alliance can be thought of as the "quality and strength of the collaborative relationship between client and therapist" (Horvath & Bedi, 2002, p. 41). It includes an emotional bond and mutual agreement on the goals of therapy, as well as the tasks involved in reaching them (Bordin, 1994, Horvath & L^uborsky, 1993). A review by Ackerman & Hilsenroth (2003), which included 25 studies of the therapeutic alliance, revealed therapist trustworthiness, experience, confidence, lucid communication, and accurate interpretation to be the most important attributes in the development and maintenance of a strong therapist-patient alliance. Therapeutic alliance has been found to be a better predictor of outcome than technique during the initial phase of therapy (Castonguay et al., 1996; Gaston, Thompson, Gallager, Coumoyer & Gagnon, 1998; Joyce & Piper, 1998; Kivlighan & Shaughnessy, 2000; Krupnick, Sotsky, Simmens, Moyer, EUcin, Watkins, & POkonis, 1996; RounsaviUe, Chevron, Prusoff, Elkin, Imber, Sotsky & Watkins, 1987; Wampold, 2001). Although the relationship between alliance and outcome is fairly robust, it does not appear to be restricted to the early phases of therapy. For example, studies by Horvath & Bedi, (2002), Horvath & Symonds (1991), and Martin et al., (2000) have reported significant, medium effect sizes ranging between .21 and .26, and suggested that 4%-7% of the variance in outcome can be explained by alliance. Research also suggests that cohesion is an important and beneficial factor for effective group process to occur. In defining cohesion, researchers have included concepts such as a sense of bonding, working together toward common goals, engagement, mutual acceptance, support, identification and affiliation with the group, and interpersonal attractiveness of the group (Marziali, Munroe-Blum & McCleary, 1997). A high degree of cohesion often improves client attendance and decreases client turnover, which are highly related to therapeutic gain (McCallum, Piper, Ogrodniczuk and Joyce, 2002; Roback and Smith, 1987; Yalom, 1995). Research has shown a positive relationship between group cohesion and positive outcomes for patients with mood disorders. For example, research comparing cohesion and successful outcome in patients with agoraphobia showed that individuals in groups where cohesion had been encouraged demonstrated significantly less fear and avoidance ratings at three and six month follow-up, compared to groups with less cohesion 56

Contribution of Group Processes

(Hand, Lamontagne & Marks, 1974; see also Budman, Demby, Feldstein, Redondo, Scherz, Bennett, Koppenaal et al., 1987; Budman, Soldz, Demby, Feldstein, Springer & Davis, 1989; Evans & Dion, 1991; Falloon, 1981; Satterfield, 1998). Similarly, in a group of smokers, Hajek, Belcher and Stapleton (1985) revealed that group cohesion was more successful in helping participants abstain from smoking at treatment termination and at one-year follow-up, compared to therapist-oriented groups in which cohesion was minimized. However, an earlier study by Teasdale, Walsh, Lancashire and Mathews (1977) failed to find a relationship between cohesion and outcome. Additionally, in a study of socially phobic clients treated with group CBT, Woody and Adessky (2002) hypothesized that cohesion would strengthen over the course of therapy and be positively related to outcome. Contrary to prediction, they found that not only was group cohesion static over time, but the level of cohesion reported was unrelated to outcome. Woody and Adessky (2002) suggested that the lack of a clear operational definition for cohesion, and the differential operationalisations used by researchers might have influenced these findings. They also suggested that the format used in their study did not involve activities with the purpose of fostering group cohesion. It could be argued that similar to Hand et al.'s (1974) unstructured (minimal cohesion) group, patients were treated as individuals in a group setting (Woody & Adessky, 2002). Recent review by Hornsey, Dywer and Oei (2006) supported the above observations and went further to suggest that Cohesion was defined too narrowly. Conversely, it could be argued that the link between cohesion and outcome is mediated by other factors, such as self-acceptance (Rugel & Barry, 1990). Given these findings, the relationship between cohesion and outcome should be interpreted with caution (Woody & Adessky, 2002). Corey and Corey (2002) have argued that the group leader's relationship and level of support with members are crucial determinants of the process and outcome of the group. Lieberman, Yalom and Miles (1973) examined the impact that the therapist's level of support and care had on patients' outcomes. They found that patients attending groups, whose leaders were low in care and support, had poor outcomes relative to those in groups with caring and supportive leaders. It should be noted however that too much support on behalf of the leader could result in members believing that they are incapable of supporting themselves. Leaders who strive for positive involvement in the group through genuine, empathetic, and caring interactions, while demonstrating support by being willing to 57

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confront members when necessary, wiU facilitate group cohesion which in turn will have a positive influence on their treatment outcomes (Corey & Corey, 2002). Another group process important to patients' outcomes is that of expressiveness, or the extent to which freedom of action and expression of feelings is encouraged (Moos, 1986). Tschuschke and Dies (1994) attempted to ascertain whether patients who expressed themselves more than other patients derived greater benefit from group psychotherapy. They found that patients who engaged in more expression of feelings and disclosure over the course of therapy experienced more favorable outcomes than those individuals who did not. The influence of independence and self-discovery in group process have yet to be comprehensively and empirically examined. Independence refers to the extent to which independent thought, action, and expression are encouraged by the group (Moos, 1986), whereas self-discovery concerns the extent to which members are encouraged by the group to reveal and discuss personal information. Intuitively, a group that is high in independence and self-discovery wiU probably be more expressive, accepting, cohesive, and less reliant on social approval, and this should have a positive affect on outcome (Cronkite et al., 1983; Moos, 1984). However, it is clear that the lack of empirical evidence exploring these processes prevents any statement as to their utility for predicting treatment outcome. In summary, it is dear that group CBT is an effective treatment for mood and anxiety disorders yet evidence remains scarce as to which group processes contribute to the positive outcome of group CBT. As such, the aim of the current study is to explore the influence of cohesion, leader support, and expressiveness together with the less examined elements of independence and self-discovery on the clinical outcomes for patients following group CBT for the treatment of anxiety and depression. These five subscales were chosen from the broader dimensions for parsimony, and because it was believed that these were most applicable in the domain of psychotherapeutic groups, based on previous literature. Specifically, given diat group therapy includes the participation of its various members, it was decided that those subscales measuring relationship dimensions and personal growth would be most pertinent in the current research at the exclusion of factors such as task orientation, order and organisation, and Innovation. It was hypothesized that these factors would each be significantly and positively related to patients' cUnical outcomes at post-treatment. 58

Contribution of Group Processes METHOD

PARTiaPANTS

Participants were 162 patients (105 female, and 57 male; Mean age = 43 years) who met the DSM-IV (APA 1994) criteria for various mood and anxiety disorders, as diagnosed by treating psychiatrists. Specifically, 65 patients were diagnosed with panic disorder with and without agoraphobia, 22 with PTSD and 9 with social phobia. In addition, 55 patients were diagnosed with Major Depressive Disorder and 11 met the diagnosis for dysthymic disorder. About 70% of the total sample had high school certificates and 30% had a diploma or degree from a university. Participants were recruited from an outpatient CBT Unit at a private hospital in Queensland, Australia, who had completed group CBT programs for either anxiety or depression between the years 2000 and 2002. Attrition from pre- to post-treatment was approximately 25%, however this was not systematic across gender and condition.
PROCEDURE

The program was delivered through a series of identical programs that were conducted between the years 2000 and 2002. The programs followed a handbook treatment protocol (for details see Oei, 1996; 1999). Each program consisted of 2 four-hour sessions per week for four weeks, and each therapy group consisted of approximately 8 to 14 patients. The psycho-educational programs included scripted minilectures, group discussions, exercises, role playing, modeling, handouts, and homework assignments. Two clinical psychologists and one psychiatric nurse were the therapists for the delivery of the programs and each session included a clinical psychologist and a nurse as group leaders. All three therapists had postgraduate qualifications in their respective professions and were experienced in the theory and application of group CBT. These procedures were similar to those described earlier (Oei & Green, 2006). At the first group therapy session, patients were requested to complete a life history and demographics questionnaire. They were told that the questionnaires provided 1) information regarding their individual problems and progress and 2) a global assessment of the treatment effectiveness for quality assurance and research purposes. Patients completed pre-andpost-treatment questionnaires, which included the Beck Anxiety Inventory and the Zung Self-Rating Depression Scale. They also completed the Group Environment Scale at completion of the treatment. These assessments are detailed below. 59

AMERICAN JOURNAL OF PSYCHOTHERAPY

MEASURES

Beck Anxiety Inventory. The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) is a 21-item self-report inventory designed to assess the severity of anxiety symptoms (e.g., subjective, neurophysiological, autonomie, and panic) in adolescents and adults. Patients are asked how much they have been bothered by particular symptoms over the past week and to rate each symptom using a 4-point scale: 0 = not at all to 3 = severely, I could barely stand it. Anxiety severity is the total raw-score sum across all 21 items, with total scores range from 0 to 63. The BAI was found to have high internal consistency (alpha = .95), and has been shown to possess good concurrent and discriminant validity by discriminating anxious diagnostic groups from other psychiatric groups (Beck et al., 1988). Zung Self-Rating Depression Scale. The Zung Self-Rating Depression Scale (Zung-SDS; Zung, 1965) is a simple procedure for evaluating the severity of clinical depression. Twenty items represent symptoms based on the clinical diagnostic criteria for depression including biological (eight items), affective (two items), and psychological (ten items). Patients rate each item in terms of its frequency using a 4-point rating scale: 1= rarely to 4 = = all or most of the time. In order to avoid problems associated with a positive response set, half of the items are worded for depression and the other half are not. The sum of the raw scores is divided by 80 and then multiplied by 100 to give an index score ranging from 25 to 100. The Zung-SDS has been found to have high internal consistency (alpha = .88), and scores are not significantly correlated with age, sex, intelligence, marital status, financial status, educational level (Zung, 1967), or the Depression Adjective Check List (Marone & Lubin, 1968). Group Environment Scale. The Group Environment ScaleEorm R (GES; Moos, 1981) was used to measure patients' perceptions of their groups' "personality" and social climate. The inventory has 90 true/false items, which includes 10 nine-item scales organized around three dimensions: relationship (cohesion, leader support, and expressiveness); personal growth (independence, task orientation, self-discovery, and anger and aggression); and system maintenance and system change (order and organization, leader control, and innovation). The current study however only utilized 45 of these items, including cohesion (e.g.. There is a feeling of unity and cohesion in this group); leader support (e.g., the leader goes out of his way to help members); expressiveness (e.g., when members disagree
60

Contribution of Group Processes

with each other, they usually say so); independence (e.g., the group helps members to become self-reliant); and self-discovery (e.g., members can discuss family problems in the group). Internal consistencies for each of the subscales were obtained and showed to be in an acceptable range; cohesion (alpha = .86), leader support (alpha = .74), expressiveness (alpha = .70), independence (alpha = ,62), and self-discovery (alpha = ,83). The intercorrelations among the 10 subscales were generally moderate, with the n;iean absolute r being ,30 (Moos et al., 1986). Test-retest reliability was also demonstrated (mean r = .76).
RESULTS

The patients' pre-and-post clinical symptomology scores were calculated on the BAI and the Zung-SDS to show the positive outcome of the program. Hierarchical regression analyses were conducted to assess whether group processes predicted post-treatment BAI and Zung-SDS scores for the patient, and to determine the strength of the relationship between the five group environment variables and positive outcome. As shown in Table 1, scores on the BAI significantly decreased from pretreatment (M = 22.61) to post-treatment (M = 14.47), t = 8.62, df= 160, p < .001, Hierarchical regression (see Table 2) revealed that after Step 1, with pre-treatment BAI scores in the equation, R = ,32, F inc (1, 144) = 67.00, p < .001. The addition of the five group environment variables collectively did not reliably improvei? = .35 (adjusted R = .32), Fine (5, 139) = 1.48,
Table I, CORRELATIONS, MEANS, AND STANDARD DEVIATIONS O F PRE-ANDPOST BAI SCORES AND VARIABLES EMPLOYED IN HIERARCHICAL REGRESSION Leader Support Self Discovery

Variables preBAI Cohesion Lead Supp Express Independ Self Disc Mean

postBAI ,56*** ,00 -,02 -,15* -,11 -,06 14,75 10,77

preBAI

Cohesion

Express

Independ

.04 -,01 -,02 -,05 ,01 22,56 13,51 .42*** ,37*** 32*** 7.22 1.97

SD

,18* .30*** ,35*** 7,83 1,27

29*** 5,82 1,62

IQ***

7,02 ,92

5,36 1,37

*p < .05, ***p < .001.

61

AMERICAN JOURNAL OF PSYCHOTHERAPY Table II. HIERARCHICAL REGRESSION EXAMINATION OF EFFECTS OF PRETREATMENT ANXIETY AND GROUP ENVIRONMENT VARIABLES ON ANXIETY LEVEL AT POST-TREATMENT

Adjusted Entry Equation(l) preBAI Equation (2) preBAI Cohesion Lead Supp Express Independ Self Disc
***p < .001.

R2

R
.56*** .32 .35 .31 .32

Change .32 .03

F Change 67.00*** 1.48

df 1,144 5,139

Beta .56 .56 .08 .01 -.17 -.04 .05

ns. Hierarchical regression results reveal that R was significantly different from zero at the end of both steps. After Step 2, with all IV's in the equation, R = .59, F (6, 139) = 12.58, p < .01. However, when looking at the contributions of each of the group environment variables separately, expressiveness was found to significantly predict post-treatment BAI scores, t (139) = 2.31, p < .05. A negative relationship between expressiveness, and post-treatment BAI scores indicates that the lower the patients anxiety at post-treatment, the higher their ratings of expressiveness within their therapy group. Table 3 displays the mean Zung-SDS scores for the patients from
Table III. CORRELATIONS, MEANS, AND STANDARD DEVIATIONS OF PREAND-POST ZUNG-SDS SCORES AND VARIABLES EMPLOYED IN HIERARCHICAL REGRESSION
PostZung PreZung Coh LS Express Independ Self Disc Mean .58*** -.06 .17* -.20** -.19** .04 56.65 11.41 PreZung Cohesion Leader Support Express Independ Self Discovery

SD

-.10 -.05 .05 -.08 -.08 65.67 12.01

.42*** .37*** .32*** .48*** 7.23 1.88

.18** .29*** .35*** 7.84 1.22

.29*** .30*** 5.82 1.55

.36*** 7.01 .88

5.41 1.34

*p < .05, **p < .01, ***p < .001.

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Contribution of Group Processes

Table IV. HIERARCHICAL REGRESSION EXAMINATION OF EFFECTS 0 1 PRETREATMENT DEPRESSION AND GROUP ENVIRONMENT VARIABLES ON DEPRESSION LEVEL AT POST-TREATMENT

Entry Equation(l) PreZung Equation (2) PreZung Cohesion Lead Supp Express Independ Self Disc
***p < .001.

R .58*** .69***

R^ .34 .47

Adjusted R^ .33 .45

R^ Change .34 .13

F Change 81.73*** 7.88***

df
L,159 5,,154

Beta .58 .60 .01 .27 .25 .16 .04

pre-treatment to post-treatment. Scores on the Zung-SDS significantly decreased from pre-treatment (M = 65.67) to post-treatment (M = 56.65), t = 10.68, df= 160, p < .001. Similarly, hierarchical regression (see Table 4) was employed for posttreatment Zung-SDS scores. At Step 1, with pre-treatment Zung-SDS scores in the equation, R = .34, F inc (1, 159) = 81.74, p < .001. At Step 2, with all rV's in the equation, R = .69, F (6, 154) - 23.14, p < .01. With the addition of the five group environment variables to the equation, R = .47, F inc (5, 154) = 7.88, p < .001. The addition of the five group environment variables collectively, reliably improved R by 13%. It is evident from these results that the group CBT programs were effective in reducing depression and anxiety patient's clinical symptomology at posttreatment as measured by the BAI and the Zung-SDS. Looking at the variables independently, it was found that neither cohesion, t (154) = .16, ns, or self-discovery t (154) = .58, ns, significantly predicted post-treatment Zung-SDS scores. However, the three remaining group environment variables significantly predicted post-treatment ZungSDS scores: leader support, t (154) - 4.13, p < .001; expressiveness, t (154) = 3.82, p < .001; and independence, t (154) = 2.51, p < .05. Altogether, 47.4% (45.4% adjusted) of the variability in patients' posttreatment Zung-SDS scores could be predicted by knowing patients pre-treatment Zung-SDS scores as well as their GES scores. Pretreatment Zung-SDS scores accounted for 34% of this total variability after Step 1,
63

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with the group environment variables accounting for the reminder 13.5% after Step 2. leader support contributed to the highest proportion of unique variance (sr = .058) to R, followed by expressiveness (sr = .050), and independence (sr = .022). A positive relationship between leader support and post-treatment Zung-SDS scores indicated that the lower the patients' depression at post-treatment, the less they rated therapist support. A negative relationship between expressiveness and post-treatment Zung-SDS scores indicated that those who reported less depression at post-treatment, reported higher perceived group expressiveness. A negative relationship between independence and post-treatment Zung-SDS scores revealed that those who reported lower depression at post-treatment, tended to report higher perceived independence within the therapy group.
DISCUSSION

The present study assessed the role that group processes play on outcomes for patients with anxiety and depression following group CBT programs. The results suggested that patients had significantly lower anxiety and depression at post-treatment compared to pre-treatment indicating the effectiveness of the therapy. It was found that increased levels of perceived expressiveness improved clinical outcomes for the patients at post-treatment. That is, the more expressive patients are in the therapy environment, the lower their anxiety and depression scores at post-treatment. This finding is consistent with previous research examining expressiveness in a group therapy setting (Tschuschke & Dies, 1994). Minimal research has been conducted examining the therapeutic effects that independence has on the group environment. However, the current study revealed that independence significantly predicted patients depression scores at post-treatment, such that the more the patients perceived a sense of independence within the therapy group, the more positive their clinical outcomes were on the Zung-SDS at post-treatment. Given the relationship between expressiveness and improved outcomes found in this study, it could be argued that expression was encouraged by the group, therefore enhancing independent thought and actions. Leader support was found to significantly predict patient's depression outcomes at post-treatment. Results suggest that decreased leader support is therapeutic for the patients, such that the less support patients felt they received from their group's leader, the more positive their clinical outcomes were at post-treatment. In contrast however, it was also found that 64

Contribution of Group Processes

the more support patients perceived from their therapist, the worse their outcomes were on the Zung-SDS. This finding would suggest that there is a level of leader support that is deemed appropriate for successful therapeutic outcome. This supports the argument by Corey and Corey (2002) that leader support is crucial in ensuring positive outcomes in group therapy, however excessive support can be counterproductive. Nonetheless, this finding would appear to be counterintuitive and it could be argued that the relationship between the individual and the therapist may be mediated by the patient's symptom severity. That is, individual differences in depression levels may benefit from either increased or decreased leader support, rather than a uniform delivery across all patients. Conversely, the current finding may simply reflect the fact that the therapist was likelier to provide more support to individuals with higher, or more observable, symptoms who in turn have poorer treatment outcomes. Despite earlier research showing that group cohesion contributes to patients' positive outcomes (e.g., Hajek, Belcher & Stapleton, 1985; Hand, Lamontagne & Marks, 1974) the current study failed to find a relationship between these two variables. This finding is consistent with that of Woody and Adessky (2002) who reported that cohesion is unrelated to outcome. It should be noted however that Woody and Adessky argued that the therapy employed in their study did not promote the development of strong bonds between members and that clients may have been treated as individuals in a group setting. The present study also failed to find a relationship between selfdiscovery and patients' clinical outcomes at post-treatment. Given that group cohesion failed to provide therapeutic value to the group members, it could be argued that this contributed to the non-significant effect of self-discovery. That is, members would be more likely to reveal personal information about themselves to a group that is more cohesive, in which members have a closer bond. It could be suggested that the group CBT programs employed in the current study were highly structured and manualised leaving little time for the patients to each freely discuss their personal issues. The present findings for both anxiety and depression are consistent with the literature (e.g. Oei & Dingle 2002; Morrison, 1999; Clark et al., 1999; Hope & Heimberg, 1993) that showed that CBT within a group format is an efficacious form of therapy. The present study adds to the literature through its specific investigation of the influence of group processes on treatment outcomes for these disorders. At this time however. 65

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the influence of these processes on the treatment outcomes for other disorders is in need of further investigation. This might provide a fruitful avenue for future research. The present study assessed the contribution of five group environment variables to clinical outcome, however a potential shortcoming arises when you consider other non-specific variables that were not measured or controlled for. For example, cohesion might have a different relationship to outcome in the presence of high levels of conflict than it might have when conflict is low (Kivlighan & LOly, 1997). Further research, therefore, needs to take the impact of other factors into consideration. A further limitation concerns the timing of the group environment measures with respect to the evaluation of treatment outcome, which may create a problem in establishing causality. Because this study is correlational, the group environment variables and outcomes are assessed at the termination of treatment. Thus, it remains unknown as to whether it is the group environment variables that have led to patients' outcomes or vice versa. It would benefit future research to administer the GES periodically throughout the course of the therapy in order to examine the development of the group process variables. In addition, the GES measures are based on retrospection and self-report measures. It should therefore be noted that results might be influenced by the participants' distorted memory and attitude towards treatment termination. Outcome studies can be extremely helpful in informing clinicians which mechanisms of change, when presented in group therapy, are likely to bring about more positive outcomes for the patients. The results show that therapists may need to make a concerted effort in encouraging patients to be open and independent in their actions and expression of feelings. In addition, therapists may need to re-evaluate the level of support they are giving to their patients. With respect to the data reported here, it seems that too much leader support can lead to unfavourable outcomes, however, future research should consider individual differences in pathology before accepting this finding. There is a hierarchy of change mechanisms involved in psychotherapy groups which outcome research to date has only touched on. In order to give full justification to the complexity of groups, further research needs to assess the interactive nature of non-specific group process variables, as well as the presence of diagnostic criteria, personality characteristics, and environmental factors, rather than the mere presence of them in psychotherapy groups. 66

Contribution of Group Processes

Preparation of this paper was partly supported hy a grant from The University of Queensland.

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