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Cohesion in Group Therapy: A Meta-Analysis
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Check My Assignment!Gary M. Burlingame, Debra Theobald McClendon, and Chongming Yang Brigham Young University
Cohesion is the most popular of the relationship constructs in the group therapy literature. This article reviews common definitions of cohesion, the most frequently studied measures, and a measure that may clarify group relations using two latent factors (quality and structure) to explain common variance among frequently used group relationship instruments. We present the results of a meta-analysis examining the relation between group cohesion and treatment outcome in 55 studies. Results indicate that the weighted aggregate correlation between cohesion and treatment outcome was statistically significant, r � .26, z � 6.54 (p � .01), reflecting a moderate effect size (d � .56). Heterogeneity of effect sizes was significant (Q � 260.84, df � 54, p � .001) and high (I2 � 79.3%), supporting moderator analyses. Six moderator variables were found to significantly predict the magnitude of the cohesion–outcome association (type of outcome measure, leader interventions to increase cohesion, theoretical orientation, type of group, emphasis on group interaction, and dose or number of group sessions). Patient contributions, diversity considerations, and evidence-based therapeutic practices are highlighted.
Clinical Impact Statement Question: Does the quality of the group therapeutic relationship predict patient improvement? Findings: Clinical efforts to enhance the therapeutic relationship in group optimize patient outcome irrespective of theoretical orientation. Meaning: Group cohesion improves outcomes in both inpa- tient and outpatient settings and across a variety of patient diagnoses. Next Steps: Test cohesion measure-informed care in group on failing states of relationship.
Keywords: group therapy, cohesion, psychotherapy relationship, meta-analysis
Cohesion is the most popular of several relationship constructs (e.g., alliance, group climate, and group atmosphere) in the clinical and empirical literature on groups. Over time it has become syn- onymous with the therapeutic relationship in group psychotherapy (Burlingame, Fuhriman, & Johnson, 2002). From the perspective of a group member, relationships comprise three structural com- ponents: member–member, member–group, and member–leader. From the perspective of the therapist, relationships include the same three components, as well as two additional ones: leader– group and, in the case of a cotherapist, leader–leader. The com- plexity of these multilevel structures coupled with their dynamic interplay 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—quality and structure—that explain common variance among these group therapy relationship instruments. We provide a clinical example to illustrate the multiple facets of cohesion in group work. We then present an original meta-analytic review of cohesion’s relation with outcome and discuss potential moderators. We highlight research limitations, patient contribu- tions, and diversity considerations. We end with a list of therapeu- tic practices that have been linked to increased cohesion. Our intent is to illuminate the coherence in the cohesion literature, present the meta-analytic conclusions, and offer measures and practices to improve treatment outcomes.
Definitions and Measures
Definitions of group cohesion have traveled a serpentine trail (Bednar & Kaul, 1994; Crouch, Bloch, & Wanlass, 1994; Kivlighan, Coleman, & Anderson, 2000), ranging from broad and diffuse (e.g., forces that cause members to remain in the group or sticking- togetherness) to focused (e.g., attractiveness or alliance) and structur- ally coherent (e.g., tripartite relationship; Yalom & Leszcz, 2005). Reviewers have pled for definitional clarity: “there is little cohesion in the cohesion research” (Bednar & Kaul, 1978, p. 800). Indeed, in- struments tapping group acceptance, emotional well-being, self- disclosure, interpersonal liking, and tolerance for personal space have been used as measures of cohesion. Behavioral definitions have included attendance, verbal content, early termination, physical seat-
Gary M. Burlingame and Debra Theobald McClendon, Department of Psychology, Brigham Young University; Chongming Yang, College of Family Home and Social Sciences, Brigham Young University.
This article is adapted, by special permission of Oxford University Press, by the same authors in J. C. Norcross & M. J. Lambert (Eds.). (2018), Psychotherapy relationships that work (3rd ed.). New York, NY: Oxford University Press. The Interdivisional APA Task Force on Evidence-Based Psychotherapy Relationships and Responsiveness was cosponsored by the APA Division of Psychotherapy/Society for the Advancement of Psycho- therapy.
Correspondence concerning this article should be addressed to Gary M. Burlingame, Department of Psychology, Brigham Young University, 238 TLRB, Provo, UT 84602. E-mail: gary_burlingame@byu.edu
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